






■ 






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Pass 7, 

Book Jj 

GopigM 

CDKRIGHT DEPOSITS 



HANDBOOK 

OF 

DISEASES OF THE RECTUM 




PLATE I. 

Cancer of the rectum complicating prolapsing hemorrhoids. Illustrating the importance 
of proctoscopic examination in all cases of apparently minor anorectal conditions. 

C. Cancer. 

N. Normal rectal mucous membrane. 

H. Hemorrhoids. 



HANDBOOK OF DISEASES 



OF THE 



RECTUM 



BY 

LOUIS J. HIKSCHMAN, M.D., F.A.C.S. 

VICE-CHAIRMAN, SECTION ON GASTROENTEROLOGY AND PROCTOLOGY, A.M. A.; EX-PRESI- 
DENT AMERICAN PROCTOLOGIC SOCIETY; PROFESSOR OF PROCTOLOGY, DETROIT 
COLLEGE OF MEDICINE; PROCTOLOGIST, HARPER HOSPITAL; MAJOR, 
M.C., U.S.A. (HONORABLY DISCHARGED), DETROIT, U.S.A. 



"IVITH T1VO HUXDRED TWEXTY-THREE ILLISTRATIOXS, 
MOSTLY ORIGINAL, AXD FOUR COLORED PLATES 



THIRD EDITION REVISED AND REWRITTEN 



ST. LOUIS 

C. V. MOSBY COMPANY 

1920 






Copyright, 1913, 1920, by C. V. Mosby Company. 



MAR 18 1920 



Press of 

C. V. Mosby Company 

St. Louis 



©CI.A565250 



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PREFACE TO THIRD EDITION 

The kind reception accorded the previous editions of this work 
necessitated a new edition several years ago. The author was at 
work on this task when this country entered the World War. His 
early departure on overseas duty with the American Expeditionary 
Forces disrupted his plans. Now that we are again at peace with 
the world, the revision has come to its completion. 

So many of the methods described have been so satisfactorily 
employed by the members of the profession that the few changes 
in technic are merely refinements. A large number of new illustra- 
tions have been added to bring these out in more detail. The whole 
text has been made as free from technical terms as is possible in a 
work of this type. The scope of this volume has been kept within 
its original limitations while the field of local anesthesia continues 
to broaden. This, it would seem, is ample justification for the 
original publication of this work. 

The author wishes to express his grateful appreciation to those 
members of the profession whose insistence is responsible for this 
edition and to the publishers and all others whose cooperation has 
always been loyally bestowed. 

Louis J. Hirschman. 

Kresge Building 
Detroit, Michigan. 



PREFACE TO SECOND EDITION 

The very generous reception which was given this book when 
first published was the best evidence that the profession was in 
need of such a work. 

The field of local anesthesia in anorectal surgery is well es- 
tablished, and in surgery generally is rapidly extending. The im- 
portance of a clear understanding of the diagnosis and treatment 
of anorectal diseases has forced itself upon the faculties of medical 
colleges and universities, with the result that an increasing number 
are giving regular courses in proctology. 

With the endeavor to make this work more valuable to the gen- 
eral practitioner, and to the student, who is the general practitioner 
of the future, this work has been completely revised. Operative 
technic has been further simplified, new diagnostic methods added, 
the use of quinin and urea anesthesia described ; the value of radiog- 
raphy in proctology illustrated by many plates ; numerous new il- 
lustrations, including two new color plates, have been added to 
more clearly assist the reader to follow out the various procedures 
described in the text. 

In the preparation of this edition the author wishes to extend 
his thanks to Dr. P. M. Hickey, Roentgenologist to Harper Hospital, 
who made all of the radiographs, and to the artists Tom Jones of 
St. Louis, and Norman Saxon Chamberlin of Detroit. 

The author also wishes to express his renewed appreciation of 
the efforts of all those who assisted in no small degree in making 
the first edition possible. 

Louis J. Hirschman. 



PREFACE TO FIRST EDITION 

In presenting this book to the medical profession, the author 
does so with the feeling that it will be of some assistance to that 
great mass who were as unfortunate as he in their early college 
training in the special field of proctology. Diseases of the rec- 
tum and anus have been, and still are, in a great many colleges, 
dismissed with a single lecture or two, delivered as a part of the 
course on general surgery. The young graduate in medicine leaves 
his Alma Mater with a hazy idea that occasionally patients may 
suffer from "piles or fistula," and an operation under general 
anesthesia is their only hope of relief. 

The fact that the profession as a whole has been so remiss in the 
treatment of patients suffering from rectal diseases has left the 
field in the past to the quack and the irregular. 

A few earnest practitioners, however, in different parts of the 
country, gradually discovered that there was something more to 
rectal diseases than the treatment of "piles and fistula" and began 
the scientific study of the lower bowel with the result that today 
the special field of proctology is firmly established with conscien- 
tious workers in all parts of the world. The results of the work of 
some of these men have been given to the world in the shape of 
most complete textbooks on the subject. In many of these works, 
however, the subject has been treated from the standpoint of the 
specialist in rectal diseases, and written for those who wish to fol- 
low that line of practice. 

With the introduction of local anesthesia into the treatment of 
diseases of the rectum and anus, a new field of work has been 
opened. Those patients suffering from many diseases of this re- 
gion, who have sought the advice and care of the irregular and 
the advertising quack, have done so on account of their dread 
of hospitals, general anesthesia, and "the knife." 

In order that the general practitioner may be qualified to diag- 
nose and treat his patient who is suffering from anorectal diseases 
as scientifically and as successfully as he does affections of other 
organs and localities, the author presents the results of his expe- 
riences in the treatment of anorectal diseases. 

9 



10 PREFACE 

The diagnosis of disease originating in this region has been dwelt 
upon to emphasize the importance of early examination. Illustra- 
tions, for the most part original, have been used wherever it has 
been thought necessary to supplement the text for the sake of 
clearness. 

Non-surgical methods are described in those conditions where 
they have been found of value, and the technic of operative meas- 
ures under local anesthesia has been made as simple as possible. 
Only those conditions which are amenable to treatment in office 
practice have been discussed, and the limitations of office treatment 
clearly set forth. For information regarding those operative meas- 
ures that are only applicable under general anesthesia, and the con- 
sideration of those diseases whose treatment requires confinement 
in bed, the reader is referred to the several complete works on 
proctology that are now available. 

Those physicians living and practicing in the Southern states, 
particularly, will appreciate the inclusion in this work of a chapter 
on Dysentery. The author has been exceedingly fortunate in se- 
curing the services of a man to prepare this chapter, than whom 
there is no one better posted on the subject: Dr. John L. Jelks, of 
Memphis, Tenn., President of the American Proctologic Society. 

Inasmuch as a very important index to the condition of the entire 
digestive tract and its functions is found in the excretions; and the 
fact that the examination of the stools, which is fully as important 
as the urinary analysis, has been too long neglected, a chapter on 
the examination of the feces has also been included. Dr. George 
W. Wagner, of Detroit, Attending Physician to Harper Hospital, 
Gastroenterologist to the German Polyclinic, and Clinical Professor 
of Medicine in the Detroit College of Medicine, has kindly contrib- 
uted this chapter, and the author considers himself extremely 
fortunate in securing the assistance of so well qualified a man. 

To the above named gentlemen; to Dr. Robert C. Jamieson, of 
Detroit, Dermatologist to Harper Hospital Polyclinic, who made the 
excellent photographs under the author's direction; to Mr. James 
T. Nolan, the artist of Western Reserve University Medical Depart- 
ment, of Cleveland, 0., who made all of the drawings; to the J. F. 
Hartz Co., of Detroit, who furnished the illustrations of many of 
the surgical instruments ; to the publishers for their hearty and 
willing cooperation ; and lastly, to the many members of the medi- 



PREFACE 11 

cal profession through whose courtesy the author has been able to 
treat the large number of cases, the results of his experience with 
them having furnished the basis for the preparation of this work — 
the author extends his sincere and heartfelt thanks. 

Besides the results of his own experience, the author has availed 
himself of the privilege of consulting many of the recent works and 
textbooks on the subject of proctology, among which may be men- 
tioned those of Tuttle, Gant, Matthews, Martin, Ball, Cripps, Wallis, 
and Hertz, as well as many articles by other authors appearing in 
the current literature of the day. 

If the author has succeeded in so simplifying the diagnosis and 
treatment of many of the more common diseases of the rectum and 
anus that this work will be of some assistance to the busy general 
practitioner in his everyday work, and has assisted in even a small 
degree in broadening the scope of the use of local anesthesia in this 
field, he will feel that he has accomplished all that he set out to do. 
This modest work does not pretend or aspire to take the place of a 
textbook on the whole subject of proctology, but if it will find a 
place on the physician's desk as a working handbook, the author 
feels that it will fill a long-felt want. 

Louis J. Hirschman. 



CONTENTS 

Chapter I 
ANATOMY 
Anus — Anal Canal — Rectum — Levator Ani — Ischiorectal Fossa — Sigmoid 

Colon — B'lood Supply — Lymphatics — Nerve Supply 21-33 

ClIAPTZR II 

SYMPTOMS WHICH SHOULD CALL ATTENTION TO THE RECTUM 
Pain — Tenderness — Spasm — Bleeding — Itching — Protrusions — Elevations 
— Discharge — Constipation — Diarrhea — Altered Stools — Sacral Back- 
ache — Shooting Pains down the Limbs — -Crampy, Painful, and 
Scanty Menstruation — Urinary Disturbances — General Disturbances 
— Anemia — Restlessness in Children — Foreign Body 31-39 

Chapter III 

EXAMINATION OF THE PATIENT 

Rooms and Furniture — Examination 40-69 

Chapter IV 

CONSTIPATION AND OBSTIPATION 
Physiology of Defecation — Etiologic Factors — Diagnosis — Treatment — 

Obstipation 70-105 

Chapter V 

FECAL IMPACTION 

Causes — Symptoms — Diagnosis — Treatment 106-109 

Chapter VI 

PRURITUS ANI 

Causes — Diagnosis — Treatment 110-126 

Chapter VII 

ANAL FISSURE AND ULCER 

Cause — Diagnosis — Treatment — Anal Ulcer . 127-113 

Chapter VIII 
ABSCESS OF THE ANORECTAL REGION 
Tegumentary Abscess — Subtegumentary or Marginal Abscess — Sub- 
mucous Abscess — Ischiorectal Abscess 141-156 

13 






14 CONTENTS 

Chapter IX 
ANAL FISTULA— ANAL SINUS 
Varieties of Fistula — Simple Complete Fistula — External Sinus — In- 
ternal Sinus — Submucous Tract — Submucous or Mucocutaneous Fis- 
tula — Injection of Bismuth Paste — Anal Fistula in the Tuberculous 
Patient 157-182 

Chapter X 

HEMORRHOIDS 

Varieties — Causes — Symptoms — Diagnosis — Treatment 183-227 

Chapter XI 

RECTAL POLYPI— HYPERTROPHIED ANAL PAPILLAE— CRYPTITIS 

Polypus— Hypertrophy of the Anal Papillse— Cryptitis 228-239 

Chapter XII 
PROCTITIS AND SIGMOIDITIS 

Acute Proctitis and Sigmoiditis— Chronic Proctitis and Sigmoiditis . . 240-252 

Chapter XIII 
DYSENTERY 

General Considerations — Acute Catarrhal Dysentery or Sporadic Bacil- 
lary Dysentery — Diphtheritic Dysentery — Secondary Diphtheritic 
Dysentery — Amebic Dysentery — Chronic or Secondary Amebic 
Dysentery 253-293 

Chapter XIV 
PROLAPSE OF THE RECTUM IN CHILDREN 

Etiology — Symptoms — Diagnosis — Treatment . , 294-301 

Chapter XV 
TECHNIC OF THE USE OF LOCAL ANESTHESIA IN THE TREATMENT 

OF ANORECTAL DISEASES 
Anesthetic Agents — Instruments — General Teclmic — Technic in Special 

Cases - 302-320 

Chapter XVI 
LIMITATIONS OF LOCAL ANESTHESIA AND OFFICE TREATMENT 

AND INDICATIONS FOR OTHER MEASURES 
General Contraindications to Local Anesthesia — Cancer of the Rectum — 
Ulceration of the Bowel — Stricture of the Rectum — Rectal Abcesses 
— Anal Fistula — Hemorrhoids — Prolapse of the Rectum — Removal of 
Concretions — Fistulas Communicating with other Organs .... 321-332 



CONTENTS 15 

Chapter XVII 
THE FECES AND THEIR CLINICAL EXAMINATION 
General Characteristics of Feces — Clinical Examination of the Stools — 
Microscopic Examination — Chemical Examination — Clinical Signifi- 
cance of Test — Animal Parasites — Character of Feces in Certain In- 
testinal Affections 333-360 

Symptom Index „ 361-363 

Index of Authorities . . 365-366 

Index 367-378 



ILLUSTRATIONS 

J 'late I. Cancer of the rectum complicating prolapsing hemorrhoids, Frontispiece 

Plate II. Blood vessels of the rectum Facing page 32 

Plate III. Giant sigmoid colon Facing page 78 

Plate IV. Section of intestine below ulceration Facing page 272 

FIG. PAGE 

1. Rectum and anal canal in the male <• .... 22 

2. Rectum hardened in formalin 24 

3. Proctoscopic view of rectal valves 26 

4. Muscles and nerves of the male pelvic outlet 28 

5. Simple form of instrument sterilizer 41 

6. Small instrument and dressing sterilizer 41 

7. Operating-table 42 

8. Electric magnifying headlight 43 

9. External inspection 44 

10. Method of applying lubricant from collapsible tube 45 

11. Incorrect method of digital examination 4G 

12. Correct method of digital examination . . 47 

13. Vaginal eversion of the anus 48 

14. Another method of everting anus .49 

15. Amount of possible eversion of anal tissues 50 

16. Method of examining the coccyx with one hand 51 

17. Rectoabdominal bimanual examination 52 

18. Rectoabdominal palpation , 53 

19. Palpation of rectum through posterior vaginal wall 53 

20. Ischiorectal abscess „ 54 

21. Squatting position 55 

22. Three-ounce, all-rubber bulb syringe 55 

23. Knee-elbow position 56 

24. Knee-shoulder position 56 

25. Author's anoscope with oblique opening 57 

26. Author's adjustable fenestrated anoscope 57 

27. Silver wire probe 58 

28. Long alligator forceps 58 

29. Kelly anoscope 59 

30. Method of using author's fenestrated anoscope 60 

31. Author's modification of Martin proctoscope 61 

32. Tuttle pneumatic proctoscope 61 

33. Exaggerated lithotomy position 62 

34. Kelly sigmoidoscope 63 

35. Sigmoidoscope with author's tilting obturator 63 

36. Adjustable proctoscopic mirror 64 

37. Inverted or Hanes' position 64 

38. Improvised arrangement for obtaining inverted position 65 

16 



ILLUSTRATIONS 



17 



fig 
39. 
40. 
41. 
42. 
43. 
44. 
45. 
46. 
47. 
48. 
49. 
50. 
51. 
52. 
53. 
54. 
5o. 
56. 
57. 
58. 
59. 
60. 
61. 
62. 
63. 
64. 
65. 
66. 
67. 
68. 
69. 
70. 
71. 
72. 
73. 
T4. 
75. 
76. 
77. 
78. 
79. 
80. 
81. 
82. 
83. 
84. 
85. 



PAGE 

Imperforate anus in one-year-old child 66 

Atresia ani vaginalis (complete) 67 

Atresia ani vaginalis (incomplete) 68 

Xormal segmentation of colon up to splenic flexure 71 

Overdistention of ascending cecum and transverse colon 72 

Megacolon 74 

Megacolon, after removal 76 

Coloptosis with angulation and adhesion of transverse colon 77 

Bismuth meal passing from ileum to cecum 80 

Whole colon injected with bismuth 81 

Ptosis of cecum „ 82 

Ptosis of cecum , 83 

Hypertrophy of pelvic colon due to adhesions „ 88 

Hypertrophy of transverse colon 89 

Congenital dilatation of pelvic colon and rectum in five-year-old boy . . 91 

Spastic descending and pelvic colon 92 

Stricture at recto-sigmoidal juncture 93 

Stricture near splenic flexure due to carcinoma 94 

Author's dilating rectal massage bag 95 

Author's dilating rectal massage bag (deflated and inflated) .... 95 

Position for author's method of rectal massage 97 

Author's four-inch operating proctoscope 101 

Author's rubber ligature carrier 101 

Author 's angular rectal scissors 101 

Technic of author 's operation for rectal valvotomy 102 

Author's rubber ligature operation 103 

Pruritus ani _ Ill 

Pruritus ani, showing excoriation 112 

External hemorrhoids with pruritus ani 114 

A simple and satisfactory rectal dressing 121 

Sharp-pointed scissors curved on the flat 122 

T-forceps 122 

Ball 's operation for pruritus ani — lines of incision 123 

Ball's operation for pruritus ani — dissecting the flap 124 

Ball 's operation for pruritus ani — area of anesthesia 125 

Krouse 's radiating incisions for Ball 's operation 126 

Typical site of anal fissure 127 

Traumatic fissure 12S 

Anal fissure with sentinel pile , 129 

Anal fissure, showing sentinel pile 130 

Multiple anal fissure 131 

Anal fissure from crypt of Morgagni 132 

Applying ointment to anus from lead tube 133 

Application of carbolic acid at point of puncture 134 

Injection of anesthetic for fissurectomy at usual site 135 

Injection of anal fissure 136 

Anesthesia and sphincteric relaxation complete for fissurectomy . . . 137 






18 ILLUSTRATIONS 

FIG. PAGE 

86. Fissure grasped ready for excision 138 

87. Simple incision of fissure 139 

88. Sharp-toothed or pronged forceps 140 

89. Anal fissure complicating internal hemorrhoids 140 

90. Author 's technic for incision of anal fissure 141 

91. Posterior anal ulcer 142 

92. Operation for excision of anal ulcer 143 

93. Anorectal abscesses 145 

94. Circumanal ulceration, infective 146 

95. Characteristic sitting posture in anorectal disease 148 

96. Proctoscopic view of submucous abscess 151 

97. De Vilbiss rectal speculum 152 

98. Line of incision for ischiorectal abscess 153 

99. Anorectal fistula — anal sinus 157 

100. Direct complete anal fistula 160 

101. Angular fistulous tract 160 

102. Glass syringe for injecting bismuth paste into fistulous openings . . 161 

103. Injection of fistulous tracts with bismuth paste 162 

104. Radiograph of simple direct complete fistula 163 

105. Complicated complete fistula 164 

106. Multiple fistula communicating with urethra 165 

107. Soft silver probe passed through complete fistula 166 

108. Grooved director 167 

109. Principal instruments for anorectal surgery under local anesthesia . . 168 

110. Fistula with three external openings 169 

111. Incision for simple direct anal fistula 170 

112. Soft silver probe passed through fistula 171 

113. Author's technic for removing fistulous tract • 173 

114. Multiple anorectal fistulse 174 

115. Excision of fistulous tract 175 

116. Fistulous area dissected clean 175 

117. Wound lightly packed with dry gauze 176 

118. Extent to which dissection must be carried in multiple fistuke . . . 178 

119. Technic of ligature operation for fistula 179 

120. Silver wire looped through fistula and fastened 180 

121. Author's cryptotome with adjustable handle 181 

122. Interno-external hemorrhoids 184 

123. Section of interno-external pile 184 

124. Acute external thrombotic hemorrhoid 185 

125. Ulcerating acute thrombotic hemorrhoid 187 

126. Acute thrombotic hemorrhoids of unusual size 188 

127. External thrombotic hemorrhoids . . . 188 

128. External cutaneous hemorrhoids 189 

129. Granulomata (syphilitic) 190 

130. Single prolapsing internal hemorrhoid 191 

131. Prolapsing internal hemorrhoids 192 



ILLUSTRATIONS 19 

FIG. PAGE 

132. Prolapsing internal hemorrhoids 193 

133. Prolapsing internal hemorrhoids 194 

134. Prolapsing internal hemorrhoids exposed ready for operation .... 195 

135. Bivalve rectal speculum 196 

136. Circumanal injection of anesthetic completed 196 

137. Showing complete anesthesia and sphincteric relaxation 197 

138. Injection of interno-external hemorrhoid 199 

139. Injection of prolapsing hemorrhoid 200 

140. Prolapsing interno-external hemorrhoids anesthetized 201 

141. Distention completed, showing internal hemorrhoids presenting . . . 202 

142. Injection of prolapsing pedunculated internal hemorrhoids .... 203 

143. Perfect exposure of operative field 204 

144. Grasping hemorrhoid with author 's hemorrhoid forceps 205 

145. Author's hemorrhoidal forceps 206 

146. Passing submucous ligature *..... 207 

147. Ligature tied with a long and a short end 208 

148. Rectal retractor modified from Sims' speculum 209 

149. Author's blunt-pointed ligature carrier 209 

150. All ligatures tied in situ 210 

151. Internal hemorrhoid anesthetized 211 

152. Excision of hemorrhoidal tissues, conserving mucosa 212 

153. The blood supply controlled by four ligatures 213 

154. Long end of ligature tied in needle . 214 

155. All hemorrhoids ligated ready to be sutured . , 215 

156. Long ends of ligatures tied to short ends 216 

157. Edges in position for suturing 217 

158. Teclmic of suturing 218 

159. Completing the suturing 219 

160. Skin closure 221 

161. Operation completed 222 

162. Distention of external hemorrhoids with sterile water 223 

163. Anal polyp 229 

164. Rectal polypus 230 

165. Specimen of multiple colonic polyposis 232 

166. Specimen from total colectomy for multiple polyposis ...... 233 

167. Hypertrophy of anal papillae and crypts of Morgagni 234 

168. Hypertrophy anal papillae 235 

169. Proctoscopic view of hypertrophied anal papilla? 236 

170. DeVilbiss spray tube 241 

171. Author's rectal spray tube 242 

172. Spraying rectum in knee-shoulder position . 243 

173. Ulcer of the rectum 244 

174. Amoeba histolytica 263 

175. Amoeba coli mitis 264 

176. Slough of mucous membrane 268 

177. Edge of intestinal ulcer 269 



20 ILLUSTRATIONS 

FIG. PAGE 

178. Dysenteric ulceration on the valves of Houston 270 

179. Photograph of case 275 

180. The Jelks' irrigating tube 286 

181. Position for irrigation of colon with Jelks' tube 287 

182. Position for introduction of colon tube 289 

183. Method of application of solutions to rectum and sigmoid 291 

184. Method of spraying rectum and sigmoid 292 

185. Prolapse of the rectum, third degree 295 

186. Prolapse of the rectum, first degree . . . 297 

187. Aseptic all-glass hypodermic syringe 307 

188. Aseptic all-metal syringe 307 

189. First step — application of carbolic acid 309 

190. Point of puncture for injecting local anesthetics .310 

191. Quadrants of the anus 311 

192. Amount of distention for anesthetizing sphincters 312 

193. Point of puncture for anesthetizing sphincterian nerves 313 

194. Producing dilatation of sphincters with vibrator 314 

j 95. Amount of dilatation of sphincter 315 

196. Anesthesia and relaxation produced by the technic outlined .... 316 

197. Wales rectal bougie 319 

198. Proctoscopic view of carcinoma 323 

199. Carcinoma after removal by operation 324 

200. Cancer of the rectum, with multiple fistula? 325 

201. Cancer of the rectum 326 

202. Cancer of the rectum, interior view , 327 

203. Sulphid of bismuth crystals from the stools 335 

204. Collective view of the feces 336 

205. Muscle remnants in feces 339 

206. Steele 's modification of Strassburger 's fermentation apparatus . . . 340 

207. Mucus shreds 341 

208. Mucus shreds after the addition of acetic acid 341 

209. Hematoidin crystals from alcoholic stools ' . 343 

210. Acholic stools 343 

211. Gallstones 346 

212 Amoeba coli 348 

213. Balantidium coli 348 

214. Ascaris lumbricoides 350 

215. Oxyuris vermicularis 351 

216. Oxyuris vermicularis 352 

217. Ankylostomum duodenale 353 

218. Trichocephalus dispar . . . . , 354 

219. Trichinae 355 

220. Anguillula stercoralis 355 

221. Head of Taenia solium 356 

222. Taenia saginata 357 

223. Head of Bothriocephalus latus 358 



DISEASES OF THE RECTUM 



CHAPTER I 

ANATOMY 

It is not the intention in a work of this scope to go into minor 
anatomical details in the description of the aims and rectum. It 
is essential, however, that one who intends to treat even the 
most common and uncomplicated diseases of the aims and rectum 
should have a practical working knowledge of the gross anatomy 
of the anorectal region. 

In reversing the usual order of describing these organs, the 
author starts with the anus first, because it is to the anal orifice 
that one's attention is first directed in proceeding to examine or 
operate for diseased conditions affecting these organs. It appears 
to the author, therefore, that the anatomy of these organs should 
be described in the order in which they are met: from without, 
inward. 

ANUS 

The anus is an oval aperture, longitudinal when in repose, 
situated at a point equidistant from the tuberosities of the ischii, 
and about one inch anterior to the tip of the coccyx. In the fe- 
male it is situated a little more anteriorly than in the male. The 
anus is surrounded by integument which is slightly darker than 
the surrounding skin. The skin around the anus is arranged in 
radiating folds caused by the contraction of the corrugator cutis 
ani muscle. The circumanal integument contains sweat glands, 
sebaceous glands, and hair follicles. The circumference of the 
anal orifice varies from an inch to an inch and three quarters, 
but it may be dilated to a circumference five or six times greater. 

21 



22 



DISEASES OF THE RECTUM 




Fig. 1. — Rectum and anal canal in the male — longitudinal section. (Section made by 
Professor A. F. Dixon of a formalin-hardened male pelvis.) — After Ball. 
B. C. Bulbocavernosus muscle. 
B. Bladder. 

P. Prostate gland. 

R. U. Rectourethralis muscle. 

S. V. Seminal vesicle with ejaculatory duct below. 
S. I. Internal sphincter muscle. 
S. F. External sphincter muscle. 
A. Anus. 

P. R. Puborectalis muscle, around which the rectum bends sharply, to be continued into 

the anal canal. 
R. Rectum. 



ANATOMY 23 

ANAL CANAL 

The anal canal extends from the point at which the sides of the 
anal aperture first appose to the linea dentata or lower edges of 
the semilunar valves, which guard the openings of the crypts of 
Morgagni. Its depth varies frcni two thirds of an inch to an 
inch and a quarter. It is lined by a membrane composed of thin 
transitional epithelium, gradually changing in histological forma- 
tion from the stratified cells of true skin at the anus to the goblet- 
cells of mucous membrane at its juncture with the rectum at the 
linea dentata, or anorectal line. Surrounding the lining mem- 
brane is one of cellular tissue, and beneath this the muscular 
layer composed of the external sphincter, a few fibers of the levator 
ani, and the lower portion of the internal sphincter. The dimensions 
of the anal canal, when in repose or dilated, are slightly smaller 
than those of the anus itself in like condition. The lining mem- 
brane presents to the eye a pinkish-red shining appearance, in 
some cases a more or less purplish hue (Fig. 1). 

External Sphincter Muscle. — This is the most important mus- 
cle with which we have to deal from a surgical point of view. 
and is the principal muscular structure which goes to form the 
anal canal. It is composed of circular and longitudinal fibers. 
The longitudinal arise from the lower end and posterior aspect 
of the coccyx, and surrounding the anus in an elliptical manner, 
meet and are inserted into the central tendon of the perineum. 
The circular fibers are more superficial, entirely surrounding the 
anal canal. The muscle is normally in a state of contraction, 
keeping the anus closed, and it is of great importance in the 
voluntary control of the act of defecation. Its nerve supply is 
derived from the third and fourth sacral and superficial branch of 
the internal puelic and a filament of the fifth and sixth sacral, 
known as the lesser sphincterian nerve. This nerve is of extreme 
importance in the production of local anesthesia for the dilation 
of the anus. It enters the external sphincter on either side at a 
point at the juncture of the lower and middle third of the anus. 

At the upper limit of the anal canal at its juncture with the 
lower portion of the rectum are situated the anal papilla 7 and 
crypts of Morgagni. The papilla? appear as a more or less dis- 
tinct line of small saw-tooth-like triangular projections which en- 



24 



DISEASES OF THE RECTUM 




K. .- 



E. — 




Fig. 2. — Rectum hardened in situ with formalin and then dissected out. — After Ball. 

S. Sacral curve of rectum. 

P. Peritoneum cut at reflexion from bowel. 

R. Portion of rectum uncovered by peritoneum. 

D. Pelvic diaphragm. 

E. External sphincter. 



ANATOMY 25 

circle the anal canal. This line is called the linea dentata, or 
anorectal line. Just behind these papillae are found the openings 
of the crypts of Morgagni. The anal papillae and crypts of Mor- 
gagni are of especial interest because they are often the seat of 
inflammatory conditions which present symptoms often out of all 
proportion to the size of the lesion causing them. 

The blood and lymphatic supply will be taken up later. 

RECTUM 

The rectum is a hollow, tubular organ varying in length from 
five to seven inches, and extending upward from the anorectal 
line to the rectosigmoidal juncture (Fig. 2). When empty, its 
anterior and posterior walls appose, and a cross-section would 
show a transverse slit. The rectum is usually understood to be 
that portion of the lower end of the large intestine which extends 
from the left sacroiliac symphysis to the anorectal line. Instead 
of it being a straight canal, as its name indicates, it is curved 
backward from the anorectal line, following the hollow of the 
sacrum, curving forward at the promontory, where it joins the 
lower portion of the sigmoid flexure. Some authors describe the 
rectum as that portion which extends from the anorectal line 
to the third sacral vertebra, which includes that portion which is 
not covered by peritoneum, the part above this being called the 
loAver end of the pelvic colon, or sigmoid colon. Inasmuch as this 
latter division has not been accepted as yet, the author will con- 
sider the rectum as described in all of the standard textbooks on 
anatomy. 

We will consider the rectum as divided in two portions : the 
upper or peritoneal portion; and the lower or that portion below 
the third sacral vertebra, the extraperitoneal. Thomas Charles 
Martin divides the rectal cavity into first, second, and third rec- 
tal chambers, each chamber corresponding to that portion below 
one of the rectal valves or folds of Houston. 

The rectum is composed of four coats, being from within out- 
ward: the mucous, submucous, muscular, and serous. The mus- 
cular coat is composed of both circular and longitudinal fibers. 
At the lower portion of the rectum and extending down to the 
white line of Hilton in the anal canal, the circular muscular fibers 



26 DISEASES OF THE RECTUM 

are more numerous and thrown together into what is known as the 
internal sphincter muscle. The mucous membrane is gathered to- 
gether in folds which converge at the anorectal line, ending at the 
crypts of Morgagni. These folds are known as the columns of Mor- 
gagni. With the patient in the knee-shoulder position and the rec- 
tum inflated, the circumference of the organ when dilated will vary 
from five to ten inches. With the rectum inflated certain definite 
crescentic folds will be seen standing out from the rectal wall, en- 
circling it for from one third to two thirds of its circumference. 
They appear at definite points and are usually three in number. 
One extremity appears attached lower to the rectal wall than the 
other, and they are arranged in such a manner that on procto- 




Fig. 3. — Proctoscopic view of the rectal valves — semidiagrammatic. 

scopic view they give the effect of three projecting ledges arranged 
in the form of a spiral ; the second being attached an inch to an inch 
and a half above the middle of the first; and the third at a point 
about the same distance above the middle of the second (Fig. 3). 
The first rectal valve, or fold of Houston, as it is called, is situated 
more often on the left lateral wall of the rectum opposite the location 
of the prostate gland, while the third is at or below the rectosig- 
moidal juncture. These valves are not simple folds of mucous mem- 
brane, but contain muscular fibers and blood-vessels and present all 
the characteristics of a typical anatomical valve. They are of con- 
siderable interest and importance because of the fact that, when 
they are infiltrated, thickened, or enlarged, they offer more or less 



ANATOMY 27 

obstruction to the passage of the fecal current and ulcerations con- 
cealed on their upper surfaces are often overlooked, whose discovery 
would clear up the etiology of many cases of so-called diarrhea. 

LEVATOR ANI MUSCLE 

Except the external sphincter muscle this is the most impor- 
tant muscle with which we have to deal (Fig. 4). With the external 
sphincter, this muscle practically controls the act of defecation. 
During defecation the levator ani and external sphincter muscles 
are relaxed, and the feces are extruded by the involuntary action 
of the muscular coats of the bowel, assisted by the voluntary com- 
pression and contraction of the abdominal muscles. The internal 
sphincter, in all probability, does not act as a sphincter at all, but 
co-operates in the peristaltic movement of the internal muscular 
coat of the intestine. When the fecal mass is extruded, the anterior 
portion of the upper portion of the anal canal is fixed by the rec- 
tourethralis muscle, which is a definite muscular band by which the 
anterior surface of the bowel at the juncture of the rectum and the 
anus is connected with the urethra. The puborectalis portion of the 
levator ani then compresses the sides and draws the posterior por- 
tion of the opening toward the pubis. 

The external sphincter then completes the evacuation and closes 
the anal canal. 

The levator ani, as described by Thompson and Ball, is com- 
posed of three main portions, the iliococcygeus, pubococcygeus, and 
puborectalis. 

Iliococcygeus.- — Although definitely attached to the ilium in many 
lower animals, in man this takes origin from the spine of the isch- 
ium and from a portion of the obturator fascia, roughly indicated 
by a white line which extends in a curve from the spine of the 
ischium to the back of the pubis. Although in older text-books this 
white line is described as a tendinous origin of the levator ani, 
recent observations tend to show that but few, if any, of the mus- 
cular fibers are actually attached to it, and that it is merely a thick- 
ening of the pelvic fascia. From this origin the iliococcygeus ex- 
tends in a fan shape to be inserted into the side of the sacrum and 
coccyx ; it is thin and in part membranous, and must be regarded as 
a degenerated muscle whose primary function in connection with 



28 



DISEASES OF THE RECTUM 



the tail is lost, but in virtue of whose position contributes to the 
formation of the pelvic floor. It has no direct relation to the rec- 
tum. 




G.M. 



Fig. 4. — Muscles and nerves of the male pelvic outlet — After Bal 

T. P. Transversus perinei muscle. 

S. E. External sphincter muscle. 

E. A. Eevator ani muscle. 

G. M. Gluteus maximus muscle. 

C. Coccyx. 

I. H. Inferior hemorrhoidal nerve. 

A. Anus. 

P. P. Posterior superficial perineal nerve. 
C. T. Central tendinous point of perineum. 

B. C. Bulbocavernosus muscle. 



Pubococcygeus. — This arises from the back of the pubis, and also 
from the obturator fascia, where usually its fibers blend with those 
of the iliococcygeus ; from the origin the fibers pass almost hori- 



ANATOMY 29 

zontally back, overlapping the iliococcygeus, closely related to 
the rectum (and vagina), to be attached to the coccyx and ano- 
coccygeal ligament. A few of the anterior fibers descend in 
front of the rectum to the perineal body, while lateral fibers are 
continued down into the aponeurotic sheath which surrounds the 
anal canal, in which the longitudinal fibers of the external coat 
of the rectum terminate. 

Puborectalis, or Sphincter Recti. — This is the name given by 
Holl to an important band of fibers of the pubococcygeus, which, 
instead of being inserted into the coccyx and its ligamentous con- 
nections, is continuous with the fibers of the same muscle on the 
other side, forming a strong muscular cord around the lateral and 
posterior aspects of the upper opening of the anal canal. The 
fibers of the puborectalis muscle arise from the back of the pubis 
on either side, under cover of the pubococcygeus, and pass be- 
tween the layers of this muscle, with more or less inter-change of 
fibers, to the back of the rectum, where they are continuous with 
the fibers of the same muscle on the other side. It is the most 
muscular portion of the levator ani, and when removed from a 
formalin-hardened body leaves a deep groove posteriorly where 
the rectum turns abruptly into the anal canal. According to 
Thompson, although traces of this muscle are found in some lower 
animals, it is only in the anthropoids that we find a muscular sling 
strongly developed for the first time, which in man has become 
evolved into such an important structure. 

LIGAMENTS 

The chief ligaments that assist in supporting the rectum are the 
anococcygeal and lateral ligaments. The anococcygeal is a cord-like 
ligament which extends from the tip of the coccyx to a point near 
the juncture of the anus and rectum on its posterior surface. At- 
tached to it are some of the more superficial fibers of the external 
sphincter. Upon either side of the rectum, just beneath the lateral 
reflections of the peritoneum, are connective-tissue attachments 
known as the lateral ligaments of the rectum. It is important to 
remember that they contain the middle hemorrhoidal vessels. 



30 DISEASES OF THE RECTUM 

RELATIONS OF THE RECTUM 

The upper half of the rectum is almost entirely surrounded by 
peritoneum. In front the peritoneum dips down between the rectum 
and bladder, forming what is known in the male as the rectovesical 
pouch; in the female the uterus and vagina take the place of the 
bladder, and the pouch is known here as Douglas' pouch. The dis- 
tance between the anus and the deepest point of dipping of this pouch 
is of great importance in the surgery of this region, and the distance 
varies, according to the measurements of different authors. The 
average distance is given as four inches. Cripps, after careful meas- 
urements of a large number of cadavers, gives the distance as 2% 
inches when the bladder and rectum are emptied, and 3% inches 
when both are distended. From this lowest point on the anterior sur- 
face of the rectum, the peritoneum gradually invests more and more 
of the rectum until its upper portion at the posterior wall of the rec- 
tum is about V/ 2 inches higher than the anterior. "Where the two 
folds of peritoneum come together behind the rectum, they form a 
complete mesentery which is continuous with that of the sigmoid. 

Other relations of the rectum are in front with the bladder, 
seminal vesicles, vas deferens, urethra, and prostate in the male; and 
the vagina, uterus, and adnexa in the female. Posteriorly it lies 
against the hollow of the sacrum and the coccyx. Laterally its upper 
portion is oftentimes in close contact with coils of the small intestine 
when they descend into the pelvis. On either side of the lower half of 
the rectum are located the ischiorectal fossce. 

ISCHIORECTAL FOSSA 

The ischiorectal space, or fossa, is a triangular space filled with 
loosely organized connective tissue and fat, situated on either side 
of the rectum between it and the tuberosity of the ischium. The 
apex of the cavity is directed upward and the base toward the 
perineum. 

Gant describes these fossa? as follows : 

"Their depth varies from one and a half inches in front to 
two inches behind, and at their lowermost and broadest part they 
are a little more than an inch in width. Internally these spaces 
are in relation to the external and internal sphincters, coccygeus, 



ANATOMY 31 

and levator ani muscles; externally with the tuber ischii and ob- 
turator fascia; anteriorly with superficial and perineal fasciae; 
and posteriorly with the border of the gluteus maximus muscles, 
the investing fascia of which is continuous with the great sacro- 
sciatic ligament. Within a sheath formed by the obturator fascia 
are to be found the internal pudic artery, veins, and nerves. The 
inferior hemorrhoidal vessels and nerves pass through the central 
portion of the ischiorectal fossae on their way to the anal canal to 
which they are distributed, while in the anterior portion of these 
spaces are the superficial perineal vessels and nerves. The fat 
and connective tissue filling these spaces act as elastic supports for 
the rectum and are largely responsible for the lateral walls of the 
rectum remaining in contact. These fossae are of surgical impor- 
tance because of the frequency with which abscesses and fistulas 
are found in this locality." 

SIGMOID COLON 

The sigmoid colon is that portion of the large intestine extend- 
ing from its juncture with the rectum at the left sacroiliac sym- 
physis to a point opposite the crest of the ileum where it becomes 
continuous with the descending colon. It derives its name of sig- 
moid colon or flexure from its double curve. It is entirely a perito- 
neal organ and is attached by a mesentery which is known as the 
mesosigmoid. Its average length is from 18 to 20 inches. . When 
empty, the greater portion of the sigmoid colon lies in the left iliac 
fossa, and a portion of it may dip down into the pelvis. When filled, 
it usually extends over and occupies the right iliac fossa as well as 
the left. It is composed of four coats corresponding to those of 
the rectum, and in addition has on its outer surface directly oppo- 
site to its mesenteric attachment a longitudinal muscular band. Its 
narrowest portion is at its juncture with the rectum. On account 
of the length of its mesocolon, the sigmoid is of importance because 
of its tendency in some cases to prolapse or become invaginated 
into the rectum. 

BLOOD SUPPLY (Plate II) 

The arteries of the rectum are the superior, middle, and inferior 
hemorrhoidal, and occasionally a branch from the middle sacral and 



32 DISEASES OF THE RECTUM 

the vesical. The largest and most important vessel is the superior 
hemorrhoidal, which is a direct continuation of the inferior mesen- 
teric. This vessel, which is situated at the posterior portion of the 
rectum, slightly to the left of the median line, passes down from the 
mesentery of the sigmoid colon to the upper portion of the rectum at 
a point about 4 to 4% inches from the anus. It here divides into two 
main branches, the right and left, which almost immediately sub- 
divide into three or four smaller branches, which run down the rec- 
tum almost to the anus, connected by a number of anastomotic 
branches, some of which pass in through the muscular coat of the 
bowel to the submucous coat where they end in a number of terminal 
branches, one being usually found in each of the columns of Mor- 
gagni. The middle hemorrhoidal artery arises from the internal iliac 
and enters the rectum on either side through the lateral ligament, 
where it breaks up into a number of branches, which supply the 
outer coats of the bowel but not the mucous membrane. The inferior 
or external hemorrhoidal arises from the internal pudic, and passing 
through the ischiorectal fossa, is distributed to the muscles of the 
anal canal. This artery supplies the cutaneous portion of the anus, 
the skin surrounding the margin of the anus, but not the mucous 
membrane. 

Venous Supply. — The veins of the rectum follow the arteries. 
The superior hemorrhoidal vein returns the blood from the rectum 
into the inferior mesenteric vein and directly to the portal circulation. 
Like the rest of the portal system, the superior hemorrhoidal vein is 
not supplied with valves. The middle and inferior hemorrhoidal 
veins return the blood from the anus and circumanal region by way 
of the internal iliac into the general venous circulation. The hemor- 
rhoidal plexus is composed of a large number of anastomosing veins 
situated in the submucous and subcutaneous tissues of the anal canal, 
and is emptied largely by the superior hemorrhoidal veins. 

LYMPHATICS 

The lymphatic vessels from the mucous membrane of the rectum 
proper communicate with a number of small glands known as the 
postrectal glands, lying between the rectum and the sacrum, from 
which lymphatic vessels pass up into the mesentery of the sigmoid. 
The lymphatics from the skin of the anus and circumanal region com- 



P. D. 



E. S. 




S. H. 



M. IT. 



I. H. 



PLATE II. 

Blood-vessels of the rectum. — After Ball. 

S. IT. Superior hemorrhoidal artery. 

M. H. Middle hemorrhoidal artery. 

I. H. Inferior hemorrhoidal artery. 

A. Anus. 

E- S. External sphincter muscle. 

P. D. Pelvic diaphragm. 

P. Cut edge of peritoneum. 



ANATOMY 33 

municate by the inner surface of the thighs with the inguinal glands. 
An important point to remember in this connection is that early in- 
volvement of the inguinal glands would indicate disease, either malig- 
nant or infectious, situated in the anal region, while malignant or 
infectious diseases of the rectum proper would extend to and infil- 
trate the presacral or postrectal, lumbar, and mesenteric glands. 

NERVE SUPPLY 

The rectum is not supplied with sensory nerves, particularly in its 
upper half. The anus and anal canal and lower portion of the rec- 
tum, on the contrary, are liberally supplied. This accounts for the 
comparative absence of pain when the rectum proper is diseased, and 
the intense suffering caused by lesions in the anal canal. The sensory 
nerves of the anus are derived from the sacral plexus. The external 
sphincter muscle receives its nerve supply by branches from the 
sacral plexus, especially the third and fourth nerves. The lesser 
sphincter ian nerve of Morestin, which is one of great importance in 
the production of local anesthesia for the dilatation of the external 
sphincter, is described by Tuttle as: "A filament coming off from the 
fifth and sixth sacral nerves which passes down the hollow of the 
sacrum through the levator ani muscle and the rectococcygeus liga- 
ment, finally reaching the posterior superficial surface of the ex- 
ternal sphincter muscle." The levator ani is also supplied by 
branches from the sacral plexus. While the anus and rectum both 
receive their nerve supply from the sympathetic and cerebrospinal 
systems, the principal nerve supply of the rectum proper is sympa- 
thetic, it receiving branches from the mesenteric, sacral, and hypo- 
gastric plexuses. From the cerebrospinal system it is supplied by 
some filaments from the third, fourth, and fifth sacral nerves. 



CHAPTER II 

SYMPTOMS WHICH SHOULD CALL ATTENTION TO THE 

RECTUM 

It lias been estimated that one patient out of every seven is suffer- 
ing from some disease, the relief of which would be assisted, or 
entirely accomplished, by the treatment of pathological conditions 
discovered only upon rectal examination. Many patients consult a 
physician, whose localized pain, swelling, hemorrhage, discharge, 
tenderness, irritation, or other symptoms call attention at once to 
the anorectal region. Many other symptoms, however, of a more 
general character— such as disturbances of digestion, menstruation, 
and the functions of urinary organs, as well as headache, backache, 
sciatica, joint pains, anemia, and sometimes even asthma and acne 
vulgaris — are more remote evidences of diseases originating within 
the confines of the loAver bowel. 

Pain. — This is the most frequent symptom which causes a patient 
to seek a physician's aid. It may be located at the anal orifice, in 
the anal canal, or the lower two inches of the rectum. It may be 
sharp, coming on suddenly, paroxysmal, burning, throbbing, or of 
a dull aching character. The character of the pain and the time of 
its onset with relation to the bowel movement are important, as 
they, of themselves, are often clues to the diagnosis. Sharp, acute 
pain, of a cutting, burning, or stinging quality, coming on with 
the stool or following it, almost invariably points to some lesion in 
the anal canal. Sudden, darting pains, occurring in the intervals 
between stools, also point to the same region for their origin. Pain 
of a throbbing character indicates acute, or subacute, inflammatory 
conditions. These may be integumentary, perianal, or perirectal 
abscesses. In these latter conditions, a rise in temperature will be 
noted, and the blood examination will show a leucocytosis. Pain 
of a dull aching character, whether intermittent or constant, may 
be caused by hemorrhoids, prolapse, polypus, fistula, ulceration of 
the rectum, benign growths — such as rectal adenoids — or malig- 
nant disease. 

34 



SYMPTOMS OF RECTAL DISEASES 35 

Many diseased conditions of the rectal cavity may progress to an 
astonishing degree without causing any local pain on account of 
the lack of sensory innervation of this region. Pain, however, re- 
ferred to other portions of the body— such as the sacrum, uterus, 
vagina, bladder, urethra, penis, scrotum, or down the sciatic nerves, 
or up into the inguinal region — is frequently caused by pathological 
conditions in the rectum, which cause no local pain whatever. 

Tenderness. — Tenderness in the circumanal region usually points 
to abscess formation or fistula. Tenderness of the anus indicates 
inflammatory conditions or ulceration. 

Spasm. — This is caused by anything Avhich irritates the sphincter 
muscles. Anal fissure, ulcer, or abscess, as well as hypertrophied 
papillae, or foreign bodies, are the usual causes of anal spasm. 

Bleeding. — This is one of the most frequent symptoms accom- 
panying diseases of the anus and rectum, and it is one of the symp- 
toms above all others which should call for complete examination 
of the anus, rectum, and sigmoid. Bleeding is more common in 
adults than in children. It may be very profuse, or slight, as simply 
a drop or two. It usually occurs during defecation, but may occur 
during the intervals as well. The blood may be discharged either 
liquid or clotted. It may be pure, or mixed with mucus, pus, feces, 
or other debris. Fresh blood discharged from the anus is usually 
from a local hemorrhage, but may have descended from the sigmoid 
or colon. The darker in color the blood, the higher in the bowel its 
source. Rectal hemorrhage may be caused: 

1. By local disease. 

2. By traumatism. 

3. Following operation. 

The cause of the last is so evident that it will not be considered, 
and trauma will simply be mentioned. The local diseases of the rec- 
tum which may cause hemorrhage are : 

1. Internal hemorrhoids. 

2. Prolapse. 

3. Fissure. 

4. Ulceration. 

5. Stricture. 

6. Malignant disease. 

7. Proctitis. 



36 DISEASES OF THE RECTUM 

8. Fecal impaction. 

9. Polyposis. 

10. Villous growths. 

11. Chancroids and chancres. 

12. Condylomata. 

Other diseases causing local rectal hemorrhage are: 

1. Dysentery, amebic or bacillary. 

2. Intussusception. 

3. Embolism of mesenteric artery. 

4. Congestion of the portal vein. 

The general systemic diseases, such as malaria, scurvy, tuber- 
culosis, typhoid fever, and others, which may during their course 
give rise to bloody stools, are not considered in this work because 
the diseased condition is very evident long before the hemorrhage 
presents itself. It may be mentioned, however, that the passage 
of some mucus streaked with blood in typhoid fever is often a 
warning signal of impending hemorrhage, and perforation. 

The type of hemorrhage characteristic of the various condi- 
tions will be taken up as each variety is discussed in its respective 
chapter. The author has seen so many cases of cancer of the 
rectum, which had gone on to almost complete occlusion of the 
rectum and involvement of other organs, whose lives might have 
been saved if proper and complete examination of the rectum had 
been made when hemorrhage first manifested itself, that he is 
constrained to lay great stress on the importance of this symptom. 
Rectal hemorrhage, no matter how slight, should never be taken 
for granted as diagnostic of hemorrhoids or any other disease, but 
shoidd call, for a complete examination, the technic of which will 
be explained in the following chapter. 

Itching. — Itching of the anus, or of the perineum, scrotum, or 
vulva, is a frequent accompanying symptom of many anal and 
rectal diseases. In fact it may occur with any of them. The 
degree and severity of the itching vary from a slight feeling of 
uneasiness and irritation, a mild pricking sensation following 
stools, to the most intense, persistent, aggravating condition char- 
acteristic of the more severe types of pruritus ani. Many con- 
stitutional diseases, such as diabetes and uric acidosis, predispose 
the patient to itching of any part of the body. When such a 



SYMPTOMS OF RECTAL DISEASES 37 

patient has a diseased condition of any part of the anorectal region, 
however slight, he usually develops pruritus ani in addition to his 
other symptoms. In the author's experience, almost every case 
showing itching as the predominating symptom has been demon- 
strated to have had its origin in some local diseased condition of 
the anorectal region. 

Protrusions. — While the most common protrusion of which the 
patient complains is some variety of hemorrhoids, it should be 
borne in mind that there are several other conditions made mani- 
fest by protrusion at the anal orifice, among which may be men- 
tioned : prolapsus, polypi, hypertrophied papillae, and cancer. In 
questioning a patient regarding a protrusion, one should find out 
whether it appears with the stools or not ; whether straining 
efforts are necessary to produce it, or whether it appears spon- 
taneously; whether it can be replaced, and if so, whether easily 
or not. One should inquire as to their number, whether they tend 
to remain outside of the sphincter, and whether or not their ap- 
pearance or replacement is accompanied by pain. 

Elevations. — Elevations found in the perianal region may be 
smooth and rounded, rough, hard, or soft and fluctuating, and are 
caused by external hemorrhoids, abscesses, lipomata, condylomata, 
or the external openings of fistulae. A rounded elevation occur- 
ring at one side of the anus, accompanied by pain of a throbbing 
character with some rise of temperature, will be found due to a 
marginal or ischiorectal abscess. A hard, rounded protuberance, 
occurring suddenly at the anal margin, accompanied by intense 
throbbing pain, will be found to be an acute thrombotic external 
hemorrhoid. A cluster of small rough elevations at the anal open- 
ing, usually posterior, is almost always condylomata. 

A small papular elevation anywhere in the perianal region from 
which a purulent discharge exudes is almost invariably the ex- 
ternal opening of a fistula. These are either single or multiple. 

Discharge. — A history of discharge from the anus should al- 
ways suggest anoscopic and proctoscopic examination. Hemor- 
rhage has already been described above. While mucus may be 
caused by any irritation, acute or chronic, and accompanies prac- 
tically all forms of rectal disease, it may originate in some in- 
flammatory condition of the colon. The sigmoid should therefore 
always be explored when a mucous discharge is observed. Purulent 



38 DISEASES OF THE RECTUM 

discharge may come from colitis, but more often points to abscess, 
internal sinus or "blind fistula," rectal ulceration, or malignant 
disease. The odor which accompanies the discharge caused by 
the last-mentioned condition is almost diagnostic in itself. Many 
patients who complain of pruritus, or local irritation of the anal 
region, will also complain of the moisture of the parts. It is well 
to bear in mind the possibility of disease of the Morgagnian 
crypts as the origin of this symptom. 

Constipation. — No case of constipation, particularly of the 
chronic variety, should ever be treated until a complete examina- 
tion has been made. So many cases of so-called constipation, 
which is purely a functional condition, are in reality due to 
mechanical causes. Coloptosis, floating kidney, prolapse, stricture, 
hypertrophied rectal valves, enlarged prostate, uterine displace- 
ments, adhesions, rectocele, perineal lacerations, fecal impaction, 
and many other diseased conditions often act in a purely mechanical 
way, causing obstipation, which can only be discovered after proper 
examination. 

Diarrhea. — Chronic diarrhea per se, or alternating with consti- 
pation, so frequently occurs as a symptom of carcinoma and ul- 
ceration, that these diseases should be excluded by examination 
before treatment is commenced. Persistent diarrhea, unaccom- 
panied by colic and pain, occurring in an apparently healthy in- 
dividual, is very suggestive of beginning malignant disease. An 
apparent diarrhea may be the involuntary passage of normal stools, 
due to a weakened condition of the sphincters caused by previous 
injury, or beginning tabes dorsalis, or other spinal disease. This 
latter condition is called sphincteric ataxia. 

Altered Stools. — Deviations from the normal appearance of the 
stools are often very suggestive, the large, hard stool of prolonged 
fecal retention giving a vastly different meaning than the narrow 
tape-like or pipe-stem stool of stricture. The color, consistency, 
and amount of the stool, as well as the appearance of blood, pus, 
or mucus with the movement, as has been noted above, are all 
of importance. 

Sacral Backache. — This is often the only subjective symptom 
of beginning malignant disease. It often accompanies internal 
hemorrhoids, prolapse, impaction, and various benign growths. It 
is a symptom which should always call for rectal examination. 



SYMPTOMS OF RECTAL DISEASES 39 

Many obstructive conditions of the sigmoid, as well as sigmoid- 
itis and fecal impaction, will often cause a sense of weight or 
constriction in the pelvis. When this occurs in females, and dis- 
eases of the uterus or adnexa are excluded by gynecological ex- 
amination, the sigmoidoscope should be used. 

Shooting' Pains Down the Limbs. — These, particularly on the 
left side, may accompany all forms of rectal disease. Sciatica 
has been so perfectly simulated by rectal ulcer that diagnosticians 
have been repeatedly led astray. This is often the predominating 
symptom in lateral ulcer of the rectum. Ischiorectal abscess, par- 
ticularly of the left fossa, frequently causes pains shooting down 
the limbs. 

Crampy, Painful, and Scanty Menstruation. — This, occurring in 
women who have perfectly normal genital organs, will be found 
upon rectal examination to be due in many cases to ulceration of 
the anterior rectal wall, fissure, or hemorrhoids. 

Urinary Disturbances. — Frequent and painful urination, pres- 
sure symptoms in the bladder, pain and burning at the vesical 
neck, enuresis: all may be due to a number of anal and rectal 
diseased conditions. Fissure and ulcer are the most frequent 
causes of bladder irritability. 

General Disturbances. — Loss of appetite, impaired digestion, 
nausea, headache, sallow complexion, and fever are frequently some 
of the symptoms of a focal infection or an autointoxication caused 
by some interference with the functions of the lower bowel, Avhose 
cause will be found upon rectal examination. 

Anemia. — Persons suffering from anemia should always be ques- 
tioned as to the existence of rectal hemorrhage, as not infrequently 
the loss of blood from internal hemorrhoids or ulceration is so ex- 
tensive as to account for the anemic condition. 

Restlessness in Children. — When children are restless at night 
and are continually picking at the nose or scratching the anus or 
genitals, an examination of the rectum will often disclose the 
presence of pinworms. 

Foreign Body. — The history of the swallowing of a foreign body, 
such as a pin or fishbone, followed in a few days by anal pain 
or tenesmus, should call for a rectal examination, and the offending 
cause of the trouble will be found not infrequently protruding from 
the mouth of one of the Morgagnian crypts. 



CHAPTER III 

EXAMINATION OF THE PATIENT 
ROOMS AND FURNITURE 

The first and most important consideration is the location and 
arrangement of the examining-room. The ideal suite of offices 
should include, besides a reception room, a consultation room, a labo- 
ratory, a toilet, an examining or operating-room, and a resting or re- 
covery room. The last two rooms should be situated at some distance 
from the reception room and should be separated from the other 
rooms by walls which are soundproof. It is not a pleasant pros- 
pect for a patient in the reception room, nervously awaiting his 
or her turn, to overhear through flimsy plaster or glass partitions 
the recital of another's ailments, or the apprehensive exclama- 
tions of a high-strung or hysterical patient on the operating table. 
Where a glass partition is all that separates the operating room 
from the reception room, those in waiting are often treated to a 
shadowgraphic representation of the performance going on within. 

One who expects to do minor surgery and treatment work should 
equip himself properly for the same. A properly fitted out and 
furnished operating-room should be provided, which could serve 
as an examining-room as well. The room should be large enough 
so as not to be uncomfortably crowded with the furniture and 
paraphernalia necessary, and yet small enough to be compact. 
The floor should be of tile or granolithic material so as to be water- 
tight and easily cleansed. The walls should be tiled, enameled, or 
treated with some material that will stand scrubbing. All corners 
should be rounded off, and as little woodwork as possible should 
enter into its construction. 

The location of the suite will depend largely upon the location 
of the building itself, but where there is a choice, it will depend 
upon whether the strongest light is desired in the forenoon or 
afternoon. Heavy shades should be provided so that the operat- 
ing or examining-room may be darkened when artificial light is 

40 ; 



EXAMINATION OF THE PATIENT 



41 



to be used. The walls and everything in the room, as far as 
possible, should be white. White gives the patient an impres- 
sion of cleanliness at once; and the slightest soiling is so con- 
spicuous that they must be kept clean. 

The necessary furniture consists of a surgical table, or chair, 
which can be adjusted to various positions; an aseptic glass and 




Fig. 5. — A simple form of instrument sterilizer for office use. 




Fig. 6. — A small instrument and dressing sterilizer. This is a very simple and popular 
form of steam sterilizer. The dressing for an office operation may be sterilized in the 
trays above the boiling instruments. 



metal instrument case ; glass-top instrument table ; revolving stool ; 
sterilizer (Figs. 5, 6), with stand; foot tub; enameled bowls 
and dressing basins, pail, compressed-air tank, and plumbing, elec- 
tric-light wiring, and other fixtures, according to the ideas of 
the individual. 

If it is not possible to have a toilet room adjoining the operat- 



42 



DISEASES OF THE RECTUM 



ing-room, a commode should be added to the equipment. A re- 
tiring or recovery room is almost a necessity as well. 

The author prefers an examining-table to a surgical chair. 
He believes that it is not more distasteful to the patient to get 
up on a table to be examined than it is to be seated in a chair 




Fig. 7. — Operating-table. This is a light but strong all-metal operating-table, particularly 
adapted for office work. It may be thrown into any position that either a surgical chair or 
table can be. 

and by the turn of a crank to be jerked or jarred, or flopped into 
position. Surgical chairs are cumbersome and always getting out 
of order, and are not to be compared with a nice, clean operat- 
ing-table of enameled iron which can be adjusted to any posi- 



EXAMINATION OF THE PATIENT 



43 



tion required (Fig. 7). Hair-stuffed cushions covered with white 
rubber and not exceeding one inch in thickness are placed on 
top of the table. The cushions should be thick enough so as 
to counteract the hardness of the table, and yet not so thick that 
the patient's buttocks sink down into them. 

Plenty of clean white sheets should be always on hand, and the 
examiner will find it more comfortable and cleanly to wear a 
white linen or duck coat, or a surgical gown. The author has 
found the electric headlight very useful where the interior of 
the rectum is to be examined, and believes it so far superior to 




Fig. 8. — Electric magnifying headlight. This is a very simple, inexpensive, and very 
satisfactory electric headlight. It may be used either on the street current or vest-pocket bat- 
tery. It is very light, compact, and can be so adjusted that the light is brought between the 
operator's eyes. There is a condensing lens which assists in focusing, thus greatly increas- 
ing its efficiency. 

the head mirror and lamp that he no longer uses the latter (Fig. 
8). 

While it is extremely desirable to have such an equipment, as 
has been described above, a very satisfactory examination can be 
made on any sort of a table or bed with the aid of a good light. 
The technic which the author uses will be described, not because 
it will be found the best by all practitioners, but because he has 
found it the best and most satisfactory in his experience. 



EXAMINATION 

The patient should first be asked into the consulting-room, and 
in order to put him at his ease, he should be allowed to tell his 



44 



DISEASES OF THE RECTUM 



story of his ailments in his own way. As he mentions symptoms 
or salient points which are pertinent, they should be noted down, 
for use in questioning him later. When he has finished, he should 
be questioned in a more systematic manner, and his history noted 
on a special blank or card kept for the purpose. The various symp- 
toms brought out in this way will often suggest a tentative diag- 
nosis, but as has been stated in the preceding chapter, nothing 
should be taken for granted and a complete rectal examination in- 




Fig. 9. — External inspection. This drawing well illustrates the posture of both ex- 
aminer and patient, and shows the extent to which the anus may be dilated by traction of 
the skin of the buttocks. 



sisted upon. The patient is then taken into the examining-room 
and prepared for the examination. All clothing, corsets, tight 
waistbands, or anything which constricts, or has a tendency to 
interfere with respiration, or to crowd the abdominal organs or 
intestines out of place, should be loosened or removed. The patient 
is then placed on the table in the left lateral or Sims position 
and covered with sheets in such a manner that there is never any 
unnecessary exposure (Fig. 9). 



EXAMINATION OF THE PATIENT 



45 



With the patient so placed as to get good daylight, or by the 
aid of the headlight, the anus, perineum, buttocks, and the genital 
organs are carefully examined. Discolorations, protrusions, ele- 
vations, swellings, abrasions, cracks, skin eruptions, crusts, scars, 
discharge, or any other abnormal appearance of the parts should 
be carefully noted. 

Digital. — With the patient in the same position, digital exam- 
ination is next in order. It is well to have in readiness a bowl of 
some antiseptic solution, preferably one which will not attack steel 
instruments. The author has found a 1:10,000 solution of mercuric 
iodid the most satisfactory. Its germicidal power is equal to that 
of the bichlorid in the strength of 1 :2,000. 




Fig. 10. — Method of applying lubricant from collapsible tube to examining finger pro- 
tected with a rubber finger cot. 



Rubber gloves or finger cots should always be used in digital ex- 
amination. The examining finger protected by the finger cot 
should always be well lubricated before an examination is attempted 
(Fig. 10). There are a number of excellent commercial lubricants 
on the market, such as Hartz's "Lubra-Septol" and Van Horn's 
"K-Y," but sterile vaselin or oil will be found to answer the pur- 
pose almost as well. The lubricant used by the author and which 
has given him perfect satisfaction is prepared as follows : 



46 



DISEASES OF THE RECTUM 



1} Hydrargyri oxycyanidi 0.240 

Glyeerini 20. 

Tragaeanthse 3. 

Aquae 100. 

Dispense in two-ounce collapsible lead tubes. 

The posture of the patient for digital examination is very im- 
portant. The old method of having a patient simply bend or 
lean over a chair or table, then inserting the index finger (Fig. 
11), is not nearly so satisfactory, comfortable, or thorough to 
either examiner or patient as the lateral or Sims position (Fig. 
12). The patient in the Sims position is relaxed and at ease, 




Fig. 11. — Tncnrrect method of digital examination. This method was deemed the only 
proper method of making a digital examination of the anus and rectum. Contrast this with 
the following illustration. 



and the parts are presented in such a manner as to give the clearest 
view and produce the most satisfactory results. 

The wearing of a glove or thin-rubber finger cot is done for 
several reasons. In the first place, it protects the wearer from in- 
fection. It also prevents the soiling of the finger with fecal ma- 
terial, pus, or discharge with their disagreeable odors. It does not 
interfere with the sense of touch, which can be educated to extreme 
delicacy even with the cot. From the patient's standpoint it is 



EXAMINATION OF THE PATIENT 



47 



much more desirable — the smooth rubber covering over the finger 
enabling it to enter much more easily than the unprotected finger, 
and there is no danger of irritating sensitive areas with the finger 
nail. If one wishes to make a digital examination, and a finger 
cot is not available, the nail of the examining finger should be 
closely trimmed, and the crevices under and around it filled by 
scratching the surface of a bar of soap. The rest of the finger 
nail should be covered with soapsuds, vaselin, or whatever lubri- 
cant is handy. After the examination, the lubricating material 




Fig. 12. — Correct method of digital examination. With the patient in the lateral or 
Sims position, the examiner standing behind the patient, digital exploration of the anus and 
rectum can he accomplished with much more thoroughness, satisfaction, and comfort to 
both. 



should be wiped from the finger with a dry cloth or absorbent 
cotton before Avashing the hands. 

The position of the patient and the examiner as well is shown 
in the accompanying illustration (Fig. 12). The protected and 
lubricated finger, which is usually the index finger of the right 
hand, is pressed against the anus with the flexor surface toward 
the posterior commissure, and the patient is asked to bear down. 



48 



DISEASES OF THE RECTUM 



The finger is first entered pointing anteriorly until the sphincters 
have been passed, and then passed backward and upward in the 
posterior direction. As the finger enters, it should be gently 
turned from side to side sweeping over all the surfaces of the 
anal canal and lower rectum. Any increase or decrease in the 
normal resistance of the sphincter muscles should be especially 
noted. Increased resistance is due to the presence of a stricture 
or some painful lesion. Diminished or absence of normal resistance 
is due to injury to the sphincters, congenital defect, or beginning 



/ 


4 




J? 




jmJ\ 


A \\ 




yll 




m 


i 








i 



Fig. 13. — Vaginal eversion of the anus. This method is useful in examining the anterior 
wall of the anus, and lower rectum in female patients, particularly those who have borne 
children and who have lax perineums. 



tabes dor sails or other spinal disease. Sphincteric ataxia is often 
one of the earliest warning signals of tabes dorsalis. Any change 
from the normal, soft, velvety feeling of this region — such as ele- 
vations, depressions, or indurations — should be carefully noted. The 
location of the feces is also important, particularly where symptoms 
of interference with normal defecation are presented. It is there- 
fore important not to give an enema before the first digital ex- 
amination. Unless one wishes to determine conditions high up in 
the rectum, or to make a rectoabdominal examination, one should 



EXAMINATION OF THE PATIENT 



49 



not feel too high in searching for the source of painful rectal 
symptoms. Most of these diseased conditions will be found within 
the first two inches from the anal outlet. Often, in inserting the 
finger, the various lesions are pushed up into the rectum, giving 
the impression that they are higher than they actually are. It is 
with the withdrawal of the finger, therefore, that more valuable in- 
formation is often obtained than on its introduction. 

Where the sphincters are so sensitive or tightly contracted as 
to prevent digital examination being accomplished without great 




Fig. 14. — Another method of everting the anal tissues for inspection. — From Crossen: 
Diagnosis and Treatment of Diseases of Women. 

pain to the patient, dilatation of the sphincters by means of local 
anesthesia should be employed. The te clinic of local anesthesia 
is fully described in Chapter XV, to which the reader is referred. 
In women much valuable information can be gained oftentimes 
by vaginorectal examination, Avhich is accomplished either by the 
index finger in the rectum and the thumb in the vagina; or by 
using the index finger of the left hand in the vagina while the 
right is in the rectum. Often in women where the perineum is 
lax, the anus may be everted by downward and outward pressure 



50 



DISEASES OF THE RECTUM 



of the index finger of the right hand in the vagina, while the 
anus is spread between the index finger and thumb of the left 
hand (Figs. 13, 14, 15). 

The lithotomy position, while in most cases not nearly so satis- 
factory for complete ocular inspection of the external parts or 
the use of the anoscope — nor as comfortable for the patient — 
has its place in the examination of the patient suffering from ano- 




Fig. 15. — Indicating the amount of possible eversion of anal tissues where the pelvic 
floor is lax, as in multipara. — Dudley : Practice of Gynecology!. 



rectal diseases. If for some reason or other the patient is not 
comfortable in the lateral position, which will occasionally be the 
case in those who suffer from rheumatism or some other joint 
affection; or on account of an unusual amount of adipose tissue 
the patient's buttocks cannot be well separated in the lateral posi- 
tion, the lithotomy position will be found much more satisfactory. 
The patient is asked to lie flat upon the table after the clothing 
has been removed, and a sheet thrown over him. The knees are 



EXAMINATION OF THE PATIENT 



51 



flexed upon the thighs, the thighs upon the abdomen, and the 
patient's buttocks pulled well down to the edge of the table. The 
legs are kept in this position either by an assistant or by the use 
of a Kelly leg holder or Clover's crutch, or by the stirrups or leg 
holders which accompany the average surgical table. In this posi- 
tion the perineal space and the perianal region can be inspected 
and palpated, and in the case of a female patient, examination of 
the genital organs carried out at the same time. In this position 
also the condition of the prostate and seminal vesicles of the male 
can be made out, and oftentimes the extent and direction of a fis- 
tulous tract determined more satisfactorily than in the lateral posi- 
tion. The condition of the coccyx can be determined with the 




Fig. 16. — Method of examining the coccyx with one hand. This may also be done with 
one hand over the region of the coccyx, posterior to and above the anus, and the index 
finger of the other inside of the rectum. — Hirst : Diseases of Women. 



patient in the lithotomy position by inserting one finger into the 
rectum with the other hand over the region of the coccyx, or by 
inserting the forefinger into the rectum with the thumb of the 
same hand over the location of the coccyx on the outside (Fig. 16). 
With the patient in the lithotomy position, bimanual abdomino- 
vaginal, and abdominorectal examinations are accomplished (Figs. 
17-20). It is a good, safe plan to include both of these methods 
in the routine examination of eveiy patient, because very fre- 



52 



DISEASES OF THE RECTUM 



quently unsuspected or beginning diseased conditions in the pelvis 
and abdomen are discovered before they have given rise to sub- 
jective symptoms. In any case presenting the symptoms of sacral 
backache, weight in the pelvis, the passage of blood or pus with 
the stool, or diarrhea, abdominorectal palpation, with the right 
index finger inserted as high as possible in the rectum, and the 
left hand over the right and left iliac fossae and above the pubes, 
is imperative. 

The squatting position (Fig. 21), or the position assumed by 
the aborginal races in defecation, is oftentimes of great value in 




Fig. 17. — Posture and method of making rectoabdominal bimanual examination. 



the diagnosis of those conditions made manifest by protrusions 
from the anal orifice. The patient is asked to remove his cloth- 
ing and to squat as if he wished to defecate. It is best to place 
a shallow basin or receptacle underneath him lest, during his 
straining efforts, feces, pus, blood, or discharge may escape. The 
patient is then asked to bear down or strain; when in this posi- 
tion, prolapsing internal hemorrhoids, polypi, or prolapse of the 
rectum or anus will be brought into view in a very satisfactory 
manner. 

Internal Inspection.— Before proceeding to internal inspection, 



EXAMINATION OF THE PATIENT 



53 



the rectum should be emptied by means of an enema of soapsuds 
and water. If one's office equipment does not include an irrigator, 
a two-quart fountain syringe will answer very nicely. Another 
very simple method is to use a three or four-ounce, soft-tipped, 
all-rubber bulb syringe, known as the ear-and-ulcer syringe (Fig. 




Fig. 18. — Method of rectoabdominal palpation. The position of both hands in relation to 
the uterus and vagina is well shown. — Montgomery : Practical Gynecology. 




Fig. 19. — Palpation of rectum through posterior vaginal wall. — Ashton: Practice of 

Gynecology. 



22). With the patient in the lateral or Sims' position a pint or 
more of solution can be gently injected, and the rectum cleansed 
in a very satisfactory manner — the patient being allowed to rise 
and go to the toilet to expel it. 

Internal inspection of the anus, rectum, and sigmoid is best 



54 



DISEASES OF THE RECTUM 



accomplished with the patient in the knee-shoulder position. The 
patient, who has been lying in the Sims' position, is asked to 
kneel on the table and to maintain the kneeling position while 
the examiner brings the left shoulder down to the table flush 
with the knees. The patient should not be allowed to rest on the 
elbows as the trunk must present enough of an inclined plane 
to allow atmospheric dilatation of the rectum, when the examining 




Fig. 20. — Ischiorectal abscess. This illustration, besides showing the point of swelling 
and fluctuation of the abscess, illustrates the method of bimanual palpation in the examination 
and diagnosis' of the condition. At the posterior commissure of the anus will be seen a 
small external hemorrhoid as well. 



instruments are inserted, and allow the other abdominal organs 
to fall away from the rectum. The accompanying illustrations 
clearly show the difference between the correct and incorrect pos- 
tures (Figs. 23, 24). 

Oftentimes the internal opening of a fistula can be determined 
by the injection through its external opening of a solution of 25 



EXAMINATION OF THE PATIENT 



55 




Fig. 21. — Squatting position. This position shows the natural posture for defecation, and 
is useful in extruding prolapsing conditions. 




Fig. 22. — Three-ounce, all-rubber bulb syringe. Useful in irrigating, and in giving enemata 
when an ordinary irrigator is not available. 



56 



DISEASES OF THE RECTUM 




Fig. 23. — Knee-elbow position. This position is often mistakenly employed in proctoscopy, 
and should not be confused with the knee-shoulder position, as depicted in the following 
illustration. 




a 



*L 



Fig. 24. — Knee-shoulder position. This is the correct posture for proctoscopic examina- 
tion. By comparing this with the preceding one, it will be seen that in the knee-shoulder 
position much more of an inclined plane is produced. Note the direction in which the 
proctoscope is introduced. 



EXAMINATION OF THE PATIENT 



57 



per cent peroxid of hydrogen. Upon examining through the 
proctoscope, while injecting, the internal opening can be easily 
located by the appearance of the bubbling peroxid solution. Solu- 
tions of methylene blue or milk of magnesia or bismuth paste 




Fig. 25. — Author's anoscope with oblique opening and slanting obturator. 




Fig. 26. — Author's adjustable fenestrated anoscope. This instrument is provided with a 
closed extremity ; has a f enestrum 1 3^ inches long by y 2 inch wide ; and can be revolved so 
that the fenestrum can be placed at any angle in relation to the handle. 



can also be used in like manner for a similar purpose. The in- 
jection of fistulous tracts with bismuth paste, as advocated by 
Emil Beck (Chap. IX), is of the greatest value in the produc- 
tion of stereoscopic radiographs. This is the refinement of diag- 



58 



DISEASES OF THE RECTUM 



nostic technic in the location of all of the ramifications of an 
anal fistula. 

For internal inspection of the anal canal, the lateral or Sims 
position is sufficient. 

Anoscopy. — The instruments required, for inspection of the anal 
canal, or anoscopy, are: a cylindrical anoscope, whose internal 
opening is oblique, and containing- an obturator tapering to a 




Fig 27. — Soft, flexible, silver wire probe. (Made easily by fusing probe points on ordi- 
nary suture wire.) 




Fig. 28. — Eong alligator forceps. These are made in different sizes, ranging from 9 to 14 
inches in length, and are very useful in proctoscopic and sigmoidoscope examination. 



blunt round extremity (Fig. 25) ; the tapering, adjustable fenes- 
trated anoscope with closed extremity (Fig. 26) ; a fine flexible 
probe (Fig. 27), made of pure silver; and a pair of dressing forceps 
(Fig. 28). An ordinary Kelly anoscope (Fig. 29) is also oftentimes 
very useful. 

Bearing in mind from the digital examination the location of 
the lesions in the anal canal, the fenestrated anoscope, well lubri- 
cated, with the opening turned so as to be opposite the lesion 



EXAMINATION OF THE PATIENT 59 

when entered, is pressed against the anus and gently inserted 
while the patient is bearing down against it (Fig. 30). If an 
opening is detected, this may be explored with the soft-silver 
probe, which may be bent easily at any angle, care being taken 
to use no force and to handle it with extreme gentleness and 
delicacy. In some cases, the instrument with the oblique opening 
is used in preference, its opening giving nearly twice the field 
of the ordinary circular opening of the Kelly instrument. The 
Kelly anoscope, however, is useful in exposing conditions which 
prolapse — the patient being asked to strain and bear down while 
the instrument is being withdrawn. 

By doing so, prolapsing hemorrhoids, prolapse of the anus or 
rectum, polypi, or papillas are brought out into view. If the view 




Fig. 29. — Kelly anoscope. Useful in prolapsing conditions. 

is obscured, at any time, a bit of cotton should be taken up with 
the dressing forceps to cleanse the parts. 

The knee-shoulder position is by far the most satisfactory in 
the author's experience for examination of the rectal cavity and 
most of the sigmoid. Not only does the atmospheric pressure 
balloon out the rectum to its fullest capacity, but this position 
also removes the pressure of other abdominal organs from the 
rectum by allowing them to fall away. 

Proctoscopy. — The only instruments required for proctoscopy 
or ocular inspection of the rectal cavity are: a cylindrical procto- 
scope, from four to six inches in length and from three quarters 
to seven eighths of an inch in diameter, and a pair of long alligator 
forceps. (Fig. 28.) In an emergency, a very fair inspection of the 



60 



DISEASES OF THE RECTUM 



rectal cavity may be had without any instruments whatever. The 
technic of proctoscopy without instruments is as follows: 

With the patient in the knee-shoulder position, the index finger 
of the right hand, protected by a finger cot, and well lubricated, 
is gently inserted, and the sphincter massaged; then the index 
finger of the left hand, similarly protected and lubricated, is in- 
troduced back to back with the finger in the rectum. The in- 




30. — Posture and method of using the author's fenestrated anoscope, for examining 

anal canal. 



the 



troduction of the second finger should be done slowly and gently 
and with a massage-like motion. When it has been introduced 
to an equal depth with its fellow, that is, up to the second joint 
of the finger, the fingers should be gently separated. The at- 
mospheric air then rushes in with an audible hiss, and the rec- 
tum balloons out so that it can be examined with the aid of the 
electric headlight or reflected light from the head mirror. 



EXAMINATION OF THE PATIENT 



61 




Fig. 31. — Author's modification of the Martin proctoscope, provided with a metal obtura- 
tor with conical extremity, which contains an air vent running through its entire length. 
It is s/z inch in diameter and 6 inches long. 




Fig. 32.— Tuttle pneumatic proctoscope. 



62 



DISEASES OF THE RECTUM 



With this method, however, one cannot see behind the rectal 
valves or folds of Houston, and it is only of value where a suit- 
able examining instrument is not at hand and the lowermost por- 
tion only of the rectal cavity is to be explored. 

The technic of proctoscopy is as follows: 

With a proctoscope whose outside diameter does not exceed the 
diameter of the operator's index finger, all parts of the rectal 
cavity can be successfully explored, and its introduction causes 
no more pain or discomfort than digital examination. The in- 





Fig. 33. — Exaggerated lithotomy position. Illustrating posture of the patient and technic 
of introduction of the sigmoidoscope. 

strument used by the author is a modification of that devised by 
T. C. Martin (Fig. 31). It is five and one-half inches long from 
the edge of the flange to the tip of the obturator. Its outside 
diameter is three quarters of an inch. It is provided with an 
obturator made of metal, with a conical extremity which fits it 
very snugly. The obturator is channeled so as to allow the in- 
gress of air during its introduction. With the patient in the 
knee-shoulder position, the well-lubricated proctoscope is pressed 
against the anus, pointing in the direction of the patient's um- 
bilicus, and the patient asked to bear down, as in the act of 



EXAMINATION OF THE PATIENT 



63 



defecation. While he is doing- so, the proctoscope is inserted 
gently, first downward and forward, until the anal canal has been 
passed; when it is tilted upward and backward and the rectal 
cavity is entered without difficulty. By asking the patient to bear 
down during the introduction of the instrument, the patient forces 
his anus down over the proctoscope, as it were, and introduction is 




Fig. 34. — Kelly sigmoidoscope. This is made in sizes varying from 8 to 14 inches in length. 




Fig. 35.— Sigmoidoscope provided with the author's tilting obturator. The tilting ob- 
turator is of value in the insertion of the sigmoidoscope, allowing it to round the sacral 
curve with greater facility. 

accomplished with much ease. Holding the proctoscope in the 
left hand, the obturator is withdrawn with the right. Inspection 
of the entire rectal cavity can then be accomplished with as much 
ease and completeness as the examination of the nose or throat. 
The proctoscope should always be entered to its fullest length 
before the obturator is withdrawn. 



64 



DISEASES OF THE RECTUM 




Fig. 36. — Adjustable proctoscopic mirror. 




- •. y> ; ;,«>,- 




Fig. 37. — Inverted or Hanes position. 



■■ 



EXAMINATION OF THE PATIENT 



65 



After examining the uppermost part of the rectum, and noting 
the appearance and condition of the rectosigmoidal juncture, it is 
slowly withdrawn, the examiner in the meanwhile noting the con- 
dition of the lining membrane of the rectum, the rectal valves, 
and the anal canal until the instrument is completely withdrawn. 
If, upon the withdrawal of the obturator, the opening of the proc- 




Fig. 38. — Improvised arrangement with ordinary operating table and pillow on floor for 

obtaining inverted position. 

toscope seems closed by a wall of rectal mucous membrane, by 
manipulating the instrument so that its inner extremity is moved 
to one side or the other, the obstruction will often be found to be 
one of the rectal valves, or folds of Houston; and on pushing this 
to one side with the instrument, a new field is exposed to view. 
With the proctoscope in position, the size, density, and thickness 
of the rectal valves can be noted by means of a probe or applicator 



66 



DISEASES OF THE RECTUM 



bent at a right angle; ulcerations of the rectal wall, their extent 
and severity, noted; the condition of the circulation of the rectum; 
the presence of polypi — in fact, any deviation from the normal, 
smooth, pearly pink appearance of the mucous membrane of the 
normal rectum easily made out by this method of examination. 
The condition of the upper surfaces of the rectal valves and the 
inner aspect of the anal canal can be accurately determined by 




Fig. 39. — Imperforate anus in one-year-old child. Injected with bismuth through in- 
guinal anus, which was made when child was forty-eight hours old. Coil of wire indicates 
normal anal site. 



the use of a small laryngoscopic mirror mounted on a long flexible 
handle (Fig. 36). While the proctoscope is in position, local ap- 
plications to diseased areas, sprays, insufflations, and other thera- 
peutic measures, when indicated, may be carried on under the 
direct guidance of the eye. The alligator forceps are useful for 
swabbing out the rectum and obtaining tissue for microscopical 
examination. 



EXAMINATION OF THE PATIENT 



67 



Sigmoidoscopy. — The exaggerated lithotomy position (Fig. 33), also 
sometimes known as the genitourinary position, is very useful 
when it is necessary to examine the sigmoid flexure. This posi- 
tion is secured by putting the patient in the lithotomy position, 
as above described, and then slowly lowering the head of the table 
so as to leave the buttocks somewhat higher than the patient's 
shoulders. This puts the patient in a sort of semi-Trendelenburg 
position with the thighs and knees flexed. In this position it will 




Fig. 40. — Atresia ani vaginalis (complete). Photograph of author's case. This illlus- 
trates a case of complete absence of the anus with the rectum emptying itself through the 
vagina. The patient was 25 years old and did not know until shortly before consulting 
the author that she was different from other people. She had partial control of her fecal 
movements by an overdevelopment of her sphincter vaginae. At the normal location of the 
anus was found a rudimentary external sphincter. The case was operated on by the 
author, the vaginal opening closed, and the rectum brought down to the normal anal site, with 
the result that the patient has an apparently normal anus with good control. The above 
photograph well shows the septum separating the rectal opening into the vagina from the 
upper vaginal canal. 

be found comparatively easy to introduce the sigmoidoscope and 
secure atmospheric dilatation of the sigmoid flexure. 

The instruments necessary for the ocular inspection of the sig- 



68 



DISEASES OF THE RECTUM 



moid flexure, or sigmoidoscopy, are sigmoidoscopes varying in 
length from nine to fourteen inches, and from five-eighths to an 
inch in circumference, and the long alligator forceps. The in- 
strument devised by Kelly (Fig. 34) is very serviceable, but its 
employment has been made much easier by the use of an obtu- 
rator whose projecting extremity tilts so as to allow of easier 
introduction in rounding the curve of the sacrum. Tuttle has 




Fig. 41. — Atresia ani vaginalis (incomplete). This photograph, taken from one of the 
author's eases, differs from the preceding in that, while the patient passed her stools through 
the vaginal opening, the anus was not entirely occluded, there being a small anovaginal 
fistula. This patient was 23 years old, and had a remarkably well-developed sphincter 
vaginae, and was able to control well her fecal movements through the vulvar orifice. This 
case was likewise operated on, and the rectum restored to its normal position with a good 
functional and cosmetic result. The external sphincter muscle was more fully developed 
in this case than in the preceding one, and control followed much more rapidly. 



devised such an instrument, as has also the author (Fig. 35). 
The only instrument required is a long alligator forceps for use 
in swabbing out the sigmoid cavity and for the purpose of re- 
moving tissue for microscopical examination. Sigmoidoscopy 



EXAMINATION OF THE PATIENT 69 

may be accomplished with the patient in the knee-shoulder posi- 
tion, but much more satisfactory results are obtained from the 
employment of the exaggerated lithotomy position. Dr. Gran- 
ville S. Hanes, of Louisville, Ky., has introduced the inverted 
position for sigmoidoscopy (Figs. 37, 38). 

The use of the pneumatic sigmoidoscope is of the highest value 
in the diagnosis of all lesions or diseased conditions located above 
the rectosigmoidal juncture. The Tuttle instrument (Fig. 32) or 
any of its modifications will be found very useful. 

Examination for Congenital Defect or Malformation. — Before 
leaving the subject of examination of the patient, the author would 
advise his readers to carefully examine every patient to make 
sure that there is not present some congenital defect or mal- 
formation of the anus or rectum (Fig. 39). Every infant at birth 
should be examined by the attending obstetrician to make sure 
that the anorectal canal is patent, as imperforate anus, while 
said to occur but once in 10,000 cases, seems to the author, in his 
own experience and that of his professional friends with whom 
he has consulted, to have occurred far more frequently. If im- 
perforate anus is not recognized, the child will die in either a 
few hours or days if the condition is not remedied, and even 
then, the operation is attended with a very high mortality; or 
nature will occasionally form a new outlet for the escape of the 
feces. In girls this happens more frequently through the vagina, 
and in male infants through the scrotum, bladder, or urethra. 
Five cases have come under the author's notice in which girls 
were allowed to grow to womanhood with congenital defects so 
serious as to preclude the possibility of marriage until remedied. 
In two (Fig. 40) there was a complete absence of an anal orifice, 
in one (Fig. 41), an aperture about one fifth of the normal size. 
In all of these cases, defecation took place through the false open- 
ing into the vagina. In the other two, a portion of the stools 
passed through both openings. 



CHAPTER IV 

CONSTIPATION AND OBSTIPATION 

Constipation is, and always will be, one of the most common 
conditions affecting the human race. Some writer has put it that 
"every other man and every woman is constipated." While this 
statement may be somewhat of an exaggeration, it is a fact never- 
theless, that constipation, or at least some interference with nor- 
mal defecation, is the most common and most prevalent affection 
of the human race. 

No patient who comes into the office of the average physician 
is turned away more quickly with a single prescription for some 
drug or combination of drugs than the constipated individual. 
This patient whose condition is one whose diagnosis cannot be 
made without a careful inquiry into his history, habits, and mode 
of living; and without a most careful and complete local exam- 
ination of the organs most involved, is the one, above all others, 
who is suffering from infrequent, irregular, or incomplete excre- 
tions from his alimentary tract, and loosely classified as the con- 
stipated patient. 

Because of thoughtless, careless, or unscientific medication by 
practitioners who are either "too busy" to give the patient the 
proper time for a careful consideration of his case, or because of 
a lack of knowledge on the part of the practitioner who has been 
graduated from college without any training in the methods of 
rectal and sigmoidal examination, or the treatment of diseases of 
the intestinal tract, particularly of the large bowel, the majority 
of patients suffering from so-called constipation have been driven 
to self -medication by means of proprietary cathartic preparations, 
and have been lost to the legimate practitioner of medicine. Many 
a patient has become a slave to cathartics and enemata, and has- 
exhausted the laxative properties of one preparation after another, 
because of the fact that when he did consult his physician he was 

70 



CONSTIPATION AND OBSTIPATION 



71 



given a prescription for "A. S\ & B. pills," or "a close of salts" 
every morning, and that was all there was to his treatment. 

Constipation may be denned as the voiding of insufficient 




Fig. 42. — Showing normal segmentation of colon up to splenic flexure. Descending colon 

contracted and atrophied. 

amounts or the abnormally prolonged retention of fecal material 
in the intestinal canal. Murray suggests that constipation should 
be denned as "The abnormal retention of waste products in the 



72 



DISEASES OF THE RECTUM 



human system." Constipation, in contradistinction to obstipa- 
tion, is due to purely functional diseases or conditions of some 
portion of the intestinal tract. Obstipation, on the other hand, is 
a condition in which there is a sufficient quantity of fecal material, 




Fig. 43. — Tremendous overdistention or ascending, cecum, and transverse colon, due to 
obstruction at splenic flexure. 



and a normal functional activity; but in which some deformity, 
growth, flexion, constricture, or foreign body in the intestinal 
canal offers a mechanical obstruction to the passage of the fecal 



CONSTIPATION AND OBSTIPATION 73 

current. These two conditions are so frequently confounded in 
the mind of the average practitioner that the distinction must be 
always borne in mind; for the treatment of these conditions, while 
they may present similar symptoms, is entirely different. 

Constipation is really but a relative condition. One individual 
may have two or three passages daily and still be constipated, 
while another individual may have but one passage a week and 
this condition be normal for him. 

Constipation in itself is not a disease but merely a symptom 
of a great many diseased conditions, but is so often the only 
apparent or "foundation" symptom of which the patient complains, 
that its discussion as a separate disease entity is deemed proper. 

Obstipation is caused by such mechanical conditions as malfor- 
mations of the intestinal canal, stricture, adhesions, pressure from 
the pregnant uterus and the various abdominal tumors, angulation, 
enteroptosis, stenosis of the ileocecal valve, fecal impaction, the 
presence of foreign bodies, hypertrophied rectal valves, prolapse 
of the rectum or sigmoid, large hemorrhoids, enlarged prostate, 
lacerated perineum, and hypertrophied or contracted sphincters. 

Chronic constipation is a condition which affects a large pro- 
portion of all the patients treated by every practitioner of med- 
icine. It is a condition which is brought about by our modern, 
so-called "strenuous life." We find it in the infant and in the 
nonagenarian. It is due to a great many factors, and in order 
that one may understand it more fully, the author will review 
some points in the physiology of peristalsis and defecation. 

PHYSIOLOGY OF DEFECATION 

Up to the last moment at which the fecal mass is expelled from 
the anus, the ingested materials are carried through the intestinal 
tract by Avhat is known as peristaltic action. 

Recent studies of intestinal peristalsis, by means of repeated 
radiographs made of the large and small intestines after the in- 
gestion of a bismuth meal, have given us some new light on the 
normal movements of the intestines. We know that it takes 
the contents of the small bowel four hours to traA T el from the 
pylorus to the cecum, the distance traversed being twenty-two and 
one-half feet in the average case. From the ileocecal valve to the 



74 



DISEASES OF THE RECTUM 



rectosigmoidal juncture the rate of progress is much slower, the 
average time being from fourteen to twenty hours. It will be 




Fig. 44. — Megacolon, or hypertrophy of entire colon, with adhesions of prolapsed transverse 

colon in right iliac fossa. 

noted, therefore, that the waste products of ingested food should 
normally be expelled approximately twenty-four hours after the 
meal. Retention longer than that period ayouIcI make the indi- 



CONSTIPATION AND OBSTIPATION 75 

vidual either a constipated or an obstipated patient, depending on 
the cause of this retention. 

After the food has entered the stomach and the albuminoids are 
converted into peptones, it passes through the pylorus into the 
small intestine. As the stomach contents pass through the pyloric 
valve, they are acid. The secretions in the small bowel — the bile 
and the pancreatic juice — being alkaline when the acid contents 
are poured into the small intestine, coming in contact with the 
alkaline intestinal secretions, a stimulation, or irritation, is caused, 
which produces a wave of muscular contraction, or peristalsis, 
called segmentation. 

At the same time that the chemical reaction of the stomach con- 
tents on those of the intestine is going on, certain gases are created. 
These gases serve to distend and increase the caliber of the bowel, 
and by this distention still further stimulate muscular contractions. 
These gases are not abnormal but serve a most useful purpose. 
It is when they are in too great quantities, and too severe per- 
istalsis and consequently too great distention of the intestinal 
canal are produced, that they are harmful. They then cause 
atony or paralysis of the circular muscle-fibers and loss of mus- 
cular tone. These gases are largely reabsorbed by the blood-ves- 
sels or discharged from the anus. If these gases in their downward 
passage meet any obstruction, they are forced backward into the 
stomach and may be discharged in this direction. The role of so- 
called hormones in the physiology of defecation has by no means 
been conclusively proved. 

Another very important source of stimulation to the coats of 
the bowel is the harsh, indigestible particles of food, familiarly 
called "ruffage," which are not acted upon by the digestive secre- 
tions. These also irritate the mucous lining of the bowel, and 
stimulate the contraction of the circular muscular fibers of the 
small intestine. Of no small importance is the stimulus caused by 
the to-and-fro movement imparted to the bowel by the movements of 
respiration. The upward and downward excursions of the dia- 
phragm impart to the small bowel in particular, but also to the trans- 
verse colon, a movement which stirs up and churns, as it were, the 
intestinal contents. The respiratory movements change the position 
of the bowel, and help to keep the intestinal contents on the move. 
It can be easily seen, therefore, how any article of clothing, or pos- 



76 



DISEASES OF THE RECTUM 



ture assumed, or certain occupations which restrict and prevent the 
full expansion of the chest will interfere with the intestinal functions 
and assist in causing constipation. 

The intestinal contents are fluid until they reach the iliocecal valve. 
In the cecum they becomes less fluid, and having to travel against the 




Fig. 45. — Specimen shown in Fig. 44 after removal. 



force of gravity, their movement in the large bowel is checked. Re- 
maining, as they do, in this portion of the bowel for fourteen to 
twenty hours, the fluid constituents are gradually absorbed, and the 
nearer to the sigmoid the feces, the more solid they become. The 
mucous membrane of the colon is thicker and not so sensitive as that 



CONSTIPATION AND OBSTIPATION 



77 



of the small intestine and requires more stimulation; consequently 
the stools are more solid in this portion of the bowel. If, however, 
an excessive amount of vegetable fiber and indigestible material is 
present, the colon tends to become overstimulated, overdistended, 




Fig. 46. — Coloptosis with angulation and adhesion of transverse colon — accentuation of 

splenic flexure. 



and atonic; the fecal mass moves very slowly, and chronic constipa- 
tion, and somtimes fecal impaction, results. The fecal material, when 
it reaches the sigmoid, rests until ready to be passed out through 
the rectum and anus, as a fecal movement. 



78 DISEASES OF THE RECTUM 

This reabsorption of the toxins mentioned above, which toxins are 
in solution, causes an antotoxemia, which in itself is responsible for 
the symptoms improperly called "bilious." The large intestine is, 
in fact, one of the most important foci for all of the symptoms now 
known to be due to ''focal infection." Among these symptoms may 
be enumerated rheumatism, neuritis, dizziness, vertigo, headache, loss 
of appetite, foul breath, mental sluggishness, a lack of ambition, 
nausea, and in some cases periodic attacks of vomiting, and a gen- 
eral feeling of fatigue and listlessness. The liver is more often up- 
set by the absorption of toxic material from the large bowel through 
the portal circulation than are the so-called syndrome of biliousness 
and so-called torpid liver causes of constipation. Bile is not nearly 
so important a factor in normal peristalsis and defecation as was 
formerly thought. Its presence does not stimulate peristalsis in the 
small intestine to any appreciable degree. In fact, its presence is 
not necessary for the production of peristalsis or defecation. It is 
merely the excretion of the liver containing the waste products re- 
maining after the liver's performance of its more important func- 
tions of detoxifying poisons that enter the body by way of the gas- 
trointestinal tract ; to store up some of the excess of fat taken as 
food, and to release it when the external supply becomes deficient ; to 
store up glycogen and to convert it into glucose and liberate it as 
required by the sj^stem; to assist in the metabolism of the proteins 
to the extent at least of forming urea or ammonia compounds, and 
other minor functions. The poor old liver has trouble of its own 
without being blamed for all of the cases of constipation in the world. 

The argument advanced by some, that the administration of a laxa- 
tive, which by increasing the flow of bile and by unloading the liver, 
empties the bowel, thereby relieving the symptoms of autointoxica- 
tion, is conclusive proof that the liver is at fault in the matter, loses 
its force entirely when we recall that many cases of autotoxemia are 
relieved by the mechanical cleansing action of an enema or colon 
flush. This, of course, acts without the assistance of the so-called nat- 
ural purgative bile. The erroneously named "liver pill" accom- 
plishes the same result by its purgative action, without regard to the 
fact of its having a cholagogic action or not. The fact that bile is 
not essential to normal defecation is illustrated very nicely in the 
normal intestinal peristalsis and defecation, taking place in patients 




# 



PLATE HI. 

Giant sigmoid colon. This case illustrates the extreme limits to which dilatation of the 
colon -will go. 

1. Volvulus at juncture of descending and sigmoid colons. 

2. Volvulus at restosigmoidal juncture. 



(From th 



courtesy 



i the anatomical laboratory of the Detroit College of Medicine, through the 
of Dr. F. N. Blanchard. 



CONSTIPATION AND OBSTIPATION 79 

suffering* from a permanent biliary fistula, and who have no bile in 
the intestinal tract at all. 

ETIOLOGIC FACTORS 

It can readily be seen that anything which interferes with the 
proper development and exercise of the intestinal musculature will 
interfere with the proper movement of the intestinal contents and 
with their expulsion at the proper time. In the first place, enough 
fluids must be taken daily into the system to keep the intestinal con- 
tents in solution and to properly supply the various organs of the 
body. On the other hand, people who do not drink sufficient water 
suffer from constipation because of the reabsorption of fluids from 
the intestinal tract and resulting hard and dry stools. People who 
drink great quantities of water with their meals do not sufficiently 
masticate and drown their stomach contents ; undigested particles of 
food are sent through the pylorus with large quantities of greatly 
diluted gastric juice ; the feeble acid reaction of this mixture does not 
cause the proper reaction with the alkaline intestinal contents; the 
proper amount of gases is not evolved, and quantities of intensely 
irritating food particles are passed down the small bowel. This is 
another cause of loss of tone. 

It is a well-known fact that carnivorous animals are constipated, 
while the herbivorous animals have full and frequent bowel move- 
ments. Realizing this fact, it therefore behooves us to see that a suf- 
ficient quantity of ruffage or vegetable material, which will leave 
undigested fiber in sufficient quantities to produce stimulation of the 
muscular fibers of the bowel, such as corn, cabbage, celery, carrots, 
beet tops, lettuce, spinach, watercress, endive, kale, and other green 
vegetables, as well as seed vegetables and fruits, is incorporated in 
our daily regimen. The dietary should also contain a sufficient 
quantity of mineral salts, particularly sodium chlorid, which are 
natural laxatives. It should also contain sweets within reasonable 
limits, because of the gas development which they cause, bearing in 
mind the fact that carbon dioxid gas is one of our best laxatives. 
Above all, the food must not be concentrated ; it must give sufficient 
bulk to the stool so that it will properly fill and distend the bowel, 
give it work to do, and thereby produce the proper stimulation to 
contraction, which is distention. The value of oatmeal, whole wheat 



80 



DISEASES OF THE RECTUM 



bread, and bran lies in the quantity of cellulose in the husk, which 
is a very important element in the stimulation of the mucous lining 
of the bowel. People who frequent the quick-lunch counter and who 
devour a full meal in ten minutes do not properly masticate their 




Fig. 47. — Bismuth meal passing from ileum to cecum (see Fig. 48). 

food, thereby causing incomplete stimuli to peristalsis, and conse- 
quently improper stools. 

Outside of dietetic error, the most common cause of constipation 



CONSTIPATION AND OBSTIPATION 



81 



is neglect. The school child receives the call of nature, the fecal mass 
is ready to be extruded, he is receiving powerful stimuli for the 
dilatation of the sphincters and the expulsion of his bowel contents; 




Fig. 48. — Same as preceding with whole colon injected with bismuth, showing distention of 
cecum, hepatic flexure, and transverse colon, angulation and looping of sigmoid. 



but in our modern schools the lesson hour is more important than the 
functions of nature ! The child is not allowed to go and relieve him- 
self. He resists and restrains nature 's efforts, and the desire passes 



82 



DISEASES OF THE RECTUM 



away. The continuance of this performance day after day soon 
makes the child chronically constipated. 




Fig. 49. — Ptosis of cecum, looping and adhesion of redundant transverse colon, and 
figure-of-eight loop replacing splenic flexure. 

While peristalsis is involuntary, in the vast majority of people the 
voluntary control over the sphincter is normally sufficient to with- 
stand peristalsis. The strong explusive efforts soon weaken when 



CONSTIPATION AND OBSTIPATION 



83 



opposed and retarded by a tightly contracted sphincter, and shortly 
the constipated habit is induced. The young girl in society is taken 




Fig. 50. — Ptosis of cecum, acute angulation of hepatic flexure, and the lower part of the 
illustration showing hypertrophy of second rectal valve. 

with a desire to move her bowels; and either because the time is 
not convenient and she restrains nature's efforts, or because she may 
be willing to satisfy nature's desire, but the location of the toilet 



84 DISEASES OF THE RECTUM 

room is such that the nature of her errand would be evident to others 
whom she would be obliged to pass, and false modesty prevents her 
from allowing her friends to see her go even in the direction of a 
retiring-room, she restrains nature's efforts, the desire soon passes 
away, and she thus becomes constipated. This is quite different from 
Continental Europe, where false modesty is unknown. When nature 
calls, she is answered, often with a promptness in public places 
which is rudely shocking to unsophisticated Americans. The fact 
remains, however, constipation is not so common in these localities. 

A very important provision in architecture of homes and other 
buildings should be the placing of toilet rooms in such inconspicuous 
places that a person may reach the same without being subject to the 
gaze of others, and the making of the seats of such a height as to 
force the user to assume a squatting posture. 

The business man, the professional man, the traveler — yes, even 
the physician — all refuse to obey nature's call, because they are too 
busy or the time does not happen to be convenient ; and thus, be- 
cause we cannot find time to move our bowels when they should be 
relieved, we have become a constipated nation. As a result, the news- 
papers, magazines, and signboards flaunt the advertisements of ca- 
thartic syrups, cathartic pills, candy cathartics, and aperient waters 
in our faces wherever we may turn. This neglect and indifference, 
in our humble opinion, is the most important cause of constipation. 

Another contributing cause to the voluntary repression of defeca- 
tion is the fact that schools, office buildings, and institutions gener- 
ally, which are occupied or inhabited by a large number of people, do 
not have anywhere near enough toilet rooms for the number of in- 
mates. Where one has to wait long for his turn, the time allowed 
and the desire for defecation is soon lost. 

The shape of the closet seat and its height from the floor are of 
importance in the production of a good stool. The seat should be so 
constructed that the person using it has to assume the squatting po- 
sition, instead of the ordinary sitting. The buttocks should be well 
separated so as to allow the free excursion of the muscles, which go to 
make up the pelvic floor, downward and upward, and the full action 
of all the other muscles involved in defecation brought into play. 

People leading sedentary lives, who do not get sufficient exercise, 
are, of course, constipated. Exercise is one of the important factors 
in keeping all of the bodily functions normal. There are many other 



CONSTIPATION AND OBSTIPATION 85 

causes which may contribute to the production of constipation in 
individual cases, but those mentioned are the most common, and by 
far the most important. 

"When the bowel has become atonic, remedies to restore its tone 
must be employed. In the treatment of acute constipation, cathartic 
drugs, suppositories, enemata. all have their proper place, but the 
victim of chronic constipation should no more be made a victim of 
the drug- habit than the patient suffering from chronic appendicitis. 
Instead of causing irritating, irregular, erratic, and violent peristal- 
tic movements at certain times during the day. and instead of chang- 
ing from one cathartic to another and increasing the dosage — instead 
of taking away the natural physiologic work of the bowel by flushing 
enemata — Ave should strive to bring that bowel back to its normal 
tone by imitating nature's method. The only place for a cathartic in 
the treatment of chronic constipation is at the beginning of the treat- 
ment. 

DIAGNOSIS 

\Yhen a patient consults you. complaining of infrequent or insuf- 
ficient bowel movements, the first thing to do is to make a diagnosis 
between constipation and obstipation. The patient should be ex- 
amined carefully ; and here the author wishes to state that, if the gen- 
eral practitioner of medicine would make it a routine practice to ex- 
amine the anus, rectum, and sigmoid of every patient who presents 
symptoms directed toward these organs, he would meet with much 
greater success: and he would discover that the treatment of ano- 
rectal diseases is not nearly so distasteful as he had heretofore 
thought. 

The author holds that no patient, presenting the symptoms of in- 
terference with the regularity or quantity of his bowel movements. 
should have any treatment, without that patient being subjected to 
a complete digital, anoscopic. proctoscopic, and often sigmoidoscope 
examination, in order to make a definite diagnosis. The patient suf- 
fering from the symptoms of constipation is just as much entitled 
to a proctologic examination as the one suffering from a cough is to 
the inspection, auscultation, and percussion of the chest. Every 
patient, male or female, should receive a bimanual rectoabdominal 
examination, and the female patient the vaginal examination in ad- 



86 DISEASES OF THE RECTUM 

clition. In the male patient the condition of the bladder and pros- 
tate should be carefully noted. 

In examining with the proctoscope, it is advisable always to place 
the patient in the knee-shoulder (Fig. 24) position, so that the rec- 
tum may be well dilated by the pressure of the atmospheric air, or 
the pneumatic proctoscope (Fig. 32) should be used. The author 
would suggest that every case suffering from constipation should be 
examined first in the constipated condition, so that the location of 
the stools in the lower bowel may be made out, and the mechanical 
obstruction, if present, located. Then an enema may be given, and 
the examination may proceed. 

If the cause is still undiscovered, radiography should be resorted 
to for a diagnosis. The technic of the injection of bismuth for 
radiography of the colon which has given me the most satisfactory 
results is as follows: 

After a cleansing enema is given, the patient is put in the left 
lateral position, and from a pint to a quart of a mixture of two 
ounces of bismuth subcarbonate to the pint of buttermilk or potato 
soup is slowly injected, using a short rectal tip. The irrigator is 
elevated two feet above the anus when the patient is in this position. 
From six to ten minutes is allowed for the injection of the fluid. As 
soon as the solution starts to flow, he is turned on his back. This al- 
lows the fluid to flow around to the cecum, and unless obstructed by 
some unusual pathologic condition, will give a good shadow. The 
flow of the opaque enema is carefully watched by means of the fluo- 
roscope, and when its progress is halted at any time, manipulation 
will assist in determining whether an obstruction is present or not. 
The site of the umbilicus is marked with a coin held in place by adhe- 
sive plaster, and stereoscopic plates made with the patient either 
lying on his abdomen, or standing with the abdomen pressed against 
an upright frame. Occasionally it will be found that the addition of 
some inert substance, such as fuller's earth in the proportion of two 
ounces to the pint, will help to make a better mixture. Also barium 
mixture is used instead of bismuth, and instead of the buttermilk, 
acacia or sugar added to a pint of water in sufficient quantity to 
make a syrup of the desired consistency will answer very nicely. 

If one is desirous of timing the activity of the small bowel, it is 
veil to administer one ounce of bismuth subcarbonate in eight ounces 



CONSTIPATION AND OBSTIPATION 87 

of buttermilk by mouth, and to make frequent fluoroscopic obser- 
vations until the bismuth is seen entering the ileocecal valve (Fig. 
47). 

The causes of many cases of so-called constipation which were ag- 
gravated in type and uninfluenced by any internal medication or 
physical therapy have been made very clear since the employment 
of radiography of the intestinal tract. A great many of these 
cases have been shown to be obstipation, the obstruction being due 
to exaggeration of the normal flexures, angulation, or ptosis, with or 
without adhesions, and the colon has been found to be the chief seat 
of the trouble in over 95 per cent of the cases. The small intestine 
is very seldom at fault. The accompanying radiographs almost tell 
their own story. 

Fig. 42 shows a total lack of function of the descending colon, due 
to atrophy of all of its coats. 

Fig. 43 shows a condition of extreme compensatory dilatation of the 
cecum, ascending and transverse colon, caused by an acute exaggera- 
tion of the normal angulation of the splenic flexure with adhesions. 
This case required exclusion of the diseased portion and ileosigmoid- 
ostomy for its relief. 

An extreme type of dilatation of the entire colon is shown in Fig. 
44. In this case coloptosis Avas also present in a marked degree, the 
transverse colon being angulated and adherent in the right iliac fossa 
below the cecum. This case required the extirpation of all of the 
colon from the cecum to the splenic flexure for relief. The section 
of bowel removed (Fig. 45) measured forty inches in length, the 
cecum fourteen inches in circumference, while at the splenic flexure 
the circumference was eight inches. When distended with water to 
the dimensions found on operation, it requires three and one-half 
quarts. This patient would go from ten to fourteen days without 
a movement, and on one occasion, went four months. 

Ptosis of the transverse colon with adhesions in the pelvis, as well 
as the exaggeration of the hepatic and splenic flexures, is well shown 
in Fig. 46, which was taken with the patient in the Trendelenburg 
position. 

The overdistention of the colon caused by nature's efforts to over- 
come an obstruction of the sigmoid is shown in Fig. 48, 51, 52. The 
acute angulations of the sigmoid will be noted, as well as the disten- 



DISEASES OF THE RECTUM 



tion of the hepatic flexure. The ileocecal juncture is well shown. 
The preceding illustration (Fig. 47) was made from the same patient 




Fig. 51. — Hypertrophy of sigmoid or pelvic colon due to adhesions at recto-sigmoidal 

juncture. 



as Fig. 48, before the bismuth was injected from below, and shows 
the bismuth meal, given ten hours previously, entering the cecum 
from the ileum. 



CONSTIPATION AND OBSTIPATION 



89 



In Fig. 49 we have a case of redundant transverse colon adherent 
and looped up under the diaphragm, and the splenic flexure replaced 




Fig - . 52. — Hypertrophy of transverse colon associated with tuberctilosis of ileo-cecal valve. 

by a figure-of-eight loop of the bowel. The cecum is enlarged and 
prolapsed, and the hepatic flexure exaggerated. 



90 DISEASES CF THE RECTUM 

In Fig. 50 we find this acute exaggeration of the hepatic flexure 
well marked. There is also distention and ptosis of the cecum, and 
the lower part of the radiograph shows the indentation made by the 
presence of a hypertrophied rectal valve. Figs. 51, 52, 53, 54, 55, and 
56 are self-explanatory, and show the great and valuable assistance 
radiography offers the proctologist, 

The series of radiographs shown here are selected from a large 
collection in the author's possession and are presented for the pur- 
pose of showing the futility of treatment directed toward the relief 
of constipation without making use of all of the diagnostic methods 
at our disposal. Every one of these cases required major surgical 
procedures for their relief, such as colectomy, exclusion, ileosigmoid- 
ostomy, resection of the diseased portions of the colon, lateral anas- 
tomosis, breaking of adhesions, mesenteric suspensions, and other 
operative measures which are not within the scope of this work. 

If, after a careful physical, proctoscopic, and radiographic ex- 
amination of the patient, none of the mechanical obstructions men- 
tioned at the beginning of this chapter are present, the case is, in all 
probability, one of functional origin, and is a true case of chronic 
atonic constipation. In the course of the examination, the dietary, 
habits, occupation, and the important facts about the patient should 
be elicited. When all examinations are completed, the question of 
treatment presents itself. 

TREATMENT 

Dietetic excesses and errors should be corrected, and the patient 
instructed as to the time, the quantity, and the kinds of food he may 
take. If he is not able to properly masticate his food, he should be 
referred to the dentist, and his teeth put in perfect shape. He should 
be instructed to drink from six to eight glasses of water in every 
twenty-four hours — a full glass of cold or hot water on arising, and 
also on retiring. He should drink plenty of water between meals, 
but very sparingly while eating. It is essential that he eat a sufficient 
amount of vegetable foods, such as have been enumerated above, and 
not to pare such fruits as pears, apples, and peaches before eating 
them. He should take plenty of outdoor exercise, such as tennis, 
golf, horseback riding, bicycle riding, and best of all, long walks in 
the open air. Breathing exercises should be indulged in, and in some 



CONSTIPATION AND OBSTIPATION 



91 



cases massage of the abdominal muscles will be necessary to restore 
their tone. The "setting up" exercises of the army can be recom- 




Fig. 53 — Congenital dilatation of sigmoid or pelvic colon and rectum in five-year-old boy. 

mended to the constipated patient, and, if persisted in, will be a 
great help in his treatment. 



92 



DISEASES OF THE RECTUM 



Any local condition, such as hemorrhoids (which of themselves 
do not cause constipation but are an effect of constipation, but by 




Fig. 54. — Spastic descending and pelvic colon. 



their pressure prevent its relief by their interference with natural 
movements), should be corrected. Fissures, ulcers, or excoriations 



CONSTIPATION AND OBSTIPATION 



93 



of the anus should be remedied by surgical means or treated locally. 
Proctitis should be relieved by the proper dietary, and medications 
applied locally. 




Fig. 55. —Stricture at recto-sigmoidal juncture. 



94 



DISEASES OF THE RECTUM 



Patients who are run down may require general massage, which 
should be given by a properly qualified masseur. If the sphincter 
is abnormally tight, it should be dilated under local or nitrous oxid 



■ 




•-. 








Fig. 56. — Stricture of transverse colon near splenic flexure due to carcinoma. 

anesthesia, or by the use of a mechanical vibrator armed with a cone- 
shaped vibratode. Most important of all, however, the atonic rectum 
and sigmoid should receive internal massage. 



CONSTIPATION AND OBSTIPATION 



95 



A great many drugless methods of treating- constipation have been 
offered to the medical profession. All kinds of electric treatments, 
external massage, cannon-balls, gymnastics, vibratory massage, baths, 




Fig. 57.-— Author's pneumatic rubber dilating rectal massage bag equipped with a hand-bulb. 









A 










B 


-4 %-,- 










~^SL <■ 


f 


X 









Fig. 5S — Author's rubber dilating rectal massage bag 

A. Bag deflated. 

B. Showing the amount of inflation necessary in the average case. 



and what not, have been tried, and while satisfactory results have 
been obtained from each of them in certain cases, there still seemed 



96 DISEASES OF THE RECTUM 

something to be desired in the successful treatment of chronic con- 
stipation without the use of cathartic drugs. 

The direct stimulation of the atonic sigmoid and rectum by means 
of mechanical dilatation has, up to the present time, given the best 
results. Rubber bags, which have been introduced through the proc- 
toscope into the sigmoid and inflated, have been used by Turck and 
others with excellent results in some cases. Tamponing the rectum 
and sigmoid with cotton, wool, or gauze, as advocated by MacMillan, 
has, by its mechanical irritation of the mucous coat of the bowel and 
its simulating the normal bowel contents, produced satisfactory eva- 
cuation, in suitable cases. The inconvenience of carrying around 
a tampon or inflated bag in the rectum or sigmoid for from four to 
six hours, or more, has, however, been a serious obstacle to the more 
general use of these methods. Wells Teachnor, of Columbus, 0., has 
successfully treated a number of cases by simple inflation of the 
rectum and sigmoid by allowing the entrance of air through the 
proctoscope, while the patient is in the knee-shoulder position, rely- 
ing on the atmospheric presence for dilatation. 

Author's Method. — The author has devised and has been using 
for many years a very simple pneumatic dilator for accomplishing 
this distention, and has achieved very happy results from its use. 

The apparatus consists of a specially shaped rubber bag (Fig. 
57) provided with a stem, which is slipped over the distal end of a 
Wales bougie (No. 3 to 5) ; the Wales bougie is channeled and con- 
tains an air vent in the handle which is closed by the finger tip 
while inflating the bag. Compressed air at a low pressure (one to 
three pounds) is allowed to slowly enter the bag, and distention to 
any desired extent is produced. By means of an ordinary cut-off 
valve and pressure reducer this distention can be easily regulated. 
Where the compressed-air apparatus is not available, an ordinary 
atomizer bulb or a small bicycle pump can be utilized. 

The technic of its use is as follows: 

The patient is placed in the Sims position. The bag is twisted 
around itself on the bougie as an umbrella is rolled on its handle, 
lubricated, and passed upward into the rectum, first anteriorly until 
the anal canal has been passed, then posteriorly following the back- 
ward curve of the sacrum, then into the sigmoid to any desired 



CONSTIPATION AXD OBSTIPATION 



97 



height. The Wales bougie, being firm enough to carry the bag up in- 
to the sigmoid, and at the same time, being flexible, does not create 
any discomfort or do any injury in its passage. It obviates the use 
of the proctoscope in its introduction. When the bag is in position, 
it is slowly inflated, until the patient complains of either fulness or 
slight crampy pain, or a desire to move the bowels (Fig. 58). The air 
is allowed to escape by removing the finger tip from the air vent in 
the handle of the bougie. Then, after an interval of five or ten sec- 
onds, it is again inflated to the point of tolerance. This treatment is 




Fig. 59. — Position for the author's method of rectal massage. This is the best position 
for both the patient and operator in treating chronic constipation with the author's dilating 
rectal massage bag. 



repeated for five to ten minutes in the average case. Then at the 
time of the last inflation, before removal, the cut-off: valve, if the 
compressed-air tank is used, is disengaged, and the opening in the 
bougie is closed with the thumb ; where the hand-bulb is used, the air 
vent in the handle of the bougie is closed with the finger tip, and then, 
by a to-and-fro motion, the apparatus is gently and slowly with- 
drawn. This method of removing the apparatus is of extreme im- 
portance as it massages the bowel as it is withdrawn, and also gently 
dilates the sphincter muscles (Fig. 59). 

This treatment is repeated daily for from five days to a week, and 



98 DISEASES OF THE RECTUM 

usually after the first or second treatment the patient will have a 
small unaided movement. Cathartics and enemata are, of course, 
strictly prohibited during the treatment. 

Each day the patient will report a slightly larger and more satis- 
factory defecation, and often more than one movement in twenty- 
four hours. The patient is instructed to have a regular definite time 
for daily evacuations, and also to go to stool at any other time during 
the day, whenever he feels the slightest inclination to have a move- 
ment. Eegularity is a very important factor in the treatment. When 
the defecation approaches the normal, treatments are given only on 
alternate days. After six or eight treatments, the interval is length- 
ened to two days, then to three, and then to four, when the patient is 
asked to report in five or six days. If he reports satisfactory evac- 
uations daily, he is allowed to go a week, and then, if a similar re- 
port is made, he is discharged as cured, but asked to return for an- 
other treatment on the first day on which he does not have a nor- 
mal movement. 

Under no circumstances is the dilator to be given to the patient for 
self -treatment. It is impossible for a patient to successfully intro- 
duce the instrument or produce sufficient dilatation on himself to 
achieve results, and most of the failures reported to the author have 
been found due to this fact. The treatment must be given by the 
physician, never by the patient. 

If the case is properly diagnosed and instructions as to a regular 
time for daily evacuations and strict obedience to nature's calls are 
faithfully carried out by the patient, as well as indulgence in a proper 
dietary, the results from this method of treatment will be very satis- 
factory, as the experience of several hundred practitioners in all 
parts of the United States and Canada will testify. 

The patient must cooperate in every way. His mental attitude 
must be attuned to his treatment. When he attempts his daily 
evacuations, he must keep his mind on his work. Suggestion plays 
a large part in the re-establishment of a normal function, and func- 
tional constipation is peculiarly susceptible to constructive sugges- 
tion. The small boy who was promised a ticket to the "movie" every 
Saturday if he had a daily movement for the preceding week, proved 
the efficacy of suggestion in this condition ! 

The only internal medication which has been found necessary in 



CONSTIPATION AND OBSTIPATION 99 

the author's experience has been the administration of extract of mix 
vomica in one-fourth to one-half-grain doses before meals as a tonic 
to asthenic or run-down individuals. Pancreatin and oxgall in 
moderate doses before meals has been found of value in patients who 
show symptoms of intestinal indigestion. In those cases where 
starchy food is found difficult of digestion the administration of taka 
diastase in doses of four to ten grains has been found of service. 
The author has experienced great satisfaction for the last sixteen 
years from the administration of white refined petroleum oil, also 
known as liquid albolene. 

This oil has no medicinal value whatever, is not a cathartic, or a 
food, and is not acted upon by any of the digestive secretions. It 
passes through the stomach and bowel and is expelled from the anus 
unchanged. It acts simply as a mechanical lubricant to the stool dur- 
ing its passage through the intestinal tract, softens hard masses 
which have been formed, and prevents the formation of others. A 
very satisfactory way of administering it is as follows: 

P* Olei ganltheriae, 

Olei menthae piperita? 

Olei earyophylli, vel 

Olei cinnamomi gtt. ii 

Petrolati liquidi §iv 

Sig: One tablespoon at bedtime. 

The dose of the oil is gradually decreased until at the end of the 
treatment it is entirely withdrawn. From a study of the reports 
sent to the author by hundreds of physicians, and from his own ex- 
perience with thousands of cases of all grades of severity and ob- 
stinacy, he would state that, if the case is properly diagnosed and 
the treatment persisted in, a cure will be effected in 85 per cent of 
the cases. In most of the failures reported to the author, correspond- 
ence with the physician usually demonstrated the fact that mechan- 
ical obstructions were present, the patient was allowed to attempt 
the use of the dilator himself, or the technic of its use was not fully 
understood. In the author's experience, one case which had existed 
for five and one-half years was cured after three treatments. An- 
other case, of 26 years' standing, who would run two weeks without 
a bowel movement, required 40 treatments extending over a period 
of two months to effect a cure. The degree of atony will govern the 



100 DISEASES OP THE RECTUM 

number of treatments and the length of time required for the treat- 
ment. The average number of treatments in the average case will 
run from ten to twenty-four. 

Other diseases occurring coincidently with, constipation have to 
be treated according to their special indications and needs. 

OBSTIPATION 

Obstipation as defined at the beginning of the chapter is a purely 
mechanical condition, there being some pathological condition which 
narrows, constricts, kinks, or obstructs the bowel in such a manner 
as to offer more resistance than normal peristalsis can overcome. 
Pressure from various abdominal organs, obstruction from coloptosis 
with or without intra-abdominal adhesions, torsion, or angulation of 
the bowel are conditions which can be remedied only by operative 
interference under general anesthesia, and do not come within the 
scope of this work. Obstipation, however, which is due to hyper- 
trophy of the rectal valves of Houston, fecal impaction, or hypertro- 
phied sphincters, is amenable to office treatment under local anes- 
thesia. 

Rectal Valves. — While for several years a great controversy was 
waged as to whether the rectal valves of Houston were really valves, 
or simply constant folds of mucous membrane, nevertheless the fact 
that fibrous hypertrophy of these structures does obstruct and im- 
pede the floAV of the fecal current is now generally admitted. The 
number of cases reported of obstipation which have been relieved, 
only after section of hypertrophied rectal valves, is now so large that 
the operation of rectal valvotomy has come to be a recognized form 
of treatment. 

Anatomical studies of the valves in situ and sections of the valve 
studied microscopically have shown conclusively that they possess 
all the elements of a typical valve. They are not simple folds of 
mucous membrane, but are composed of : first, mucous membrane ; 
second, a fibrous tissue layer; third, a circular muscular layer; 
fourth, a longitudinal muscular layer; and fifth, a subserous layer 
consisting of areolar tissue and fat, and containing arteries, veins, 
nerves, and lymphatics. Under certain conditions these rectal valves 
become thickened and stiffened by the increased deposition of fibrous 
tissue, in fact, become almost leathery in consistency. They usually 



CONSTIPATION AND OBSTIPATION 



101 



encroach upon the lumen of the bowel. They may not become in- 
creased in thickness whatever, but may be simply increased in area 
so that they occupy from one half to three quarters or more of the 




Fig. 60. — Author's four-inch operating proctoscope. 




Fig. 61. — Author's rubber ligature carrier or valvotomy needle. 




Fig. 62. — Author's angular rectal scissors. A very useful instrument for any cutting 
operation performed through the operating proctoscope. 



rectal lumen. Sometimes one valve may be enlarged, and sometimes 
two or three. This form of enlargement presents a firm and un- 
yielding barrier to the normal descent of the feces. 

Patients with so-called constipation who have run the whole gamut 



102 



DISEASES OF THE RECTUM 



of cathartics, enemata, massage, dietetics, electricity, osteopathy, and 
"Christian Science" have not been relieved until they have had a 
proper proctologic examination and the enlarged rectal valves which 
were discovered reduced by valvotomy. The author has had re- 
peatedly such cases referred to him, and the operation of valvotomy 
has relieved a large percentage of these cases. 

The operation as performed on most of these patients was a modi- 
fication of that first introduced by T. C. Martin, of Washington. It 
was a delicate operation, requiring considerable skill and special ap- 
paratus, but the results were all that could be desired. The objec- 



^ 




Fig. 63. — Technic of author's operation for rectal valvotomy. This drawing shows the 
position of the patient in the knee-shoulder position, with the author's valvotomy needle 
threaded with a rubber ligature transfixing the first rectal valve. 

tions were : first, that without a general anesthetic patients became 
wearied and restless before the operation was completed ; second, the 
fact that a general anesthetic was required for a number of cases; 
third, that in cases of unusually large blood-vessels in the valve con- 
siderable difficulty was experienced with hemorrhage; fourth, that 
the patient was confined in his house or bed or the hospital for 
from four or five days to a week. 

The Gant clamp and the Pennington clip greatly simplified the 
operation of valvotomy, so much so, that it could be done in a very 



CONSTIPATION AND OBSTIPATION 



103 




B. 




Fig. 64. — Author's rubber-ligature operation for rectal valvotomy (drawn from 

proctoscopic view). 

A. Rubber ligature in place with lead fastener ready for compression. 

B. Ligature drawn taut, and lead fastener compressed, showing amount of constriction. 

C. Result three weeks after operation. 



104 DISEASES OF THE RECTUM 

few minutes in the physician's office without any anesthesia. The 
objection to the use of these mechanical contrivances was the fact 
of the possibility of their being carried up higher into the bowel 
after cutting through unless secured by a cord passing outside the 
anus, and worn there until the instrument was discharged, and also 
trauma of the rectal mucous membrane caused by the retention and 
passage of these irregularly shaped, hard, metallic bodies. 

Author's Operation for Rectal Valvotomy. — The author has de- 
vised an extremely simple technic, which has proved most satisfac- 
tory in his hands, and which by reference to the accompanying illus- 
trations can be readily understood (Figs. 60-64). The sphincter is 
first anesthetized and dilated, according to the technic described in 
Chapter XV. The patient is then placed in the knee-shoulder posi- 
tion, and a large operating-sized proctoscope (Fig. 60) inserted. The 
author's ligature carrier or valvotomy needle (Fig. 61) is threaded 
through the eye at the curve with a rubber ligature (sizes 5 to 8, 
French scale). The ligature passes inside of the curve of the needle 
and should project at least three inches from the point. The needle 
which is nine inches long and has a handle bent at an angle so as 
not to obstruct the view, is then passed up and around and hooked 
through the highest offending valve until the point is projected and 
the ligature can be clearly seen. This end is then grasped by means 
of a long alligator forceps, and the ligature is pulled through until 
it is outside the proctoscope. The needle is then passed back and 
around the edge of the valve and is brought down also outside the 
proctoscope, and is then taken off the ligature. The ligature is now T 
in place (Fig. 64A). Over the ends is slipped a lead fastener or large 
perforated shot, the ligature being put on the extreme stretch, and 
the shot grasped and pushed up to the valve tightly by means of long 
compression forceps and crushed. This puckers the valve (Fig. 
64B), and constricts it in such a way that circulation is shut off, and 
the ligature sloughs through in from two to eight days. After the 
ligature has cut through, the edges retract so that a large U-shaped 
opening is left, which gradually still further retracts. Fig. 64C 
shows the retraction in cases in which the rectal valve contains a 
considerable amount of fibroelastic tissue. 
The advantages of this simple technic are as follows: 
1. It can be done without any anesthetic whatever. 



CONSTIPATION AND OBSTIPATION 105 

2. It can be done quickly ; the whole operation should not require 
more than ten minutes for three valves. 

3. It requires few instruments or appliances. 

4. The patient is not confined in bed. 

5. There is absolutely no hemorrhage ; no stitches are required. 

6. The rubber ligature, being soft and non-irritating, does not 
scratch or bruise the bowel in situ or during its expulsion, and there 
is no clanger of its doing damage if it should by any possibility be 
carried up higher into the bowel. 

7. It is simple. 






CHAPTER V 

FECAL IMPACTION 

This consists in the formation and retention in some part of the 
intestinal canal of a mass of hardened feces. In 70 per cent of the 
cases the fecal impaction is found in the rectum, and in 20 per cent 
in the sigmoid flexure. The other 10 per cent are found in the 
upper portions of the intestinal canal, which do not come within 
the scope of this work, and will not be discussed. 



CAUSES 

Anything which interferes with the regularity of defecation may 
cause the formation of an impaction. Decubitus incident to illness 
or convalescence from surgical operations is a common predispos- 
ing cause. A diet which is too concentrated, such as the ordinary 
milk diet, is very apt to produce impaction. 

Overdistention of the boAvel caused by constipation may lead to 
the formation of a pouch or diverticulum. This pouch becomes 
filled with fecal matter, and on account of the atonic condition of 
its muscular fibers, is unable to completely empty itself during def- 
ecation. This leads to absorption of the fluid constituents of the 
stool and leaves behind a hardened fecal mass, whose consistency 
ranges from that of stiff clay to calcareous, as in enteroliths, or 
fecal concretions, which are composed largely of lime salts. Bits 
of bone, fruit and vegetable seeds, fruit stones, indigestible vege- 
table fiber, concretions of bismuth, salol, magnesia, or other insolu- 
ble drugs, taken internally, may become the nidus of a fecal con- 
cretion, which in turn is frequently the underlying cause of fecal 
impaction. Gallstones may also be responsible for their formation. 

SYMPTOMS 

The symptoms of fecal impaction are those of obstipation, coming 
on rather suddenly with more or less intestinal distention, accom- 

106 



FECAL IMPACTION 107 

panied with pain in the rectum, and extending to the left inguinal 
region, and frequently shooting down the left leg. The patient will 
complain of a frequent desire for stool, but inability to accomplish 
the same on account of a sense of weight and blocking-up of the 
rectum. If the impaction is low he may feel it impinging on the 
anus following the effort at expulsion. The pressure on, and irrita- 
tion of, the mucous membrane, caused by the presence of this hard 
foreign body, starts up a hypersecretion of mucus and causes ulcer- 
ation of the bowel. This causes in many instances, a diarrhea, 
characterized by frequent, small irritating, watery, and mucous 
stools, which often contain blood and frequently pus. 

Cases have been reported in which the impaction has become 
channeled, where, after a period of almost complete obstruction, 
the patients have had stools apparently normal. In cases where 
the impaction occurs in a pouch, or diverticulum, this may also 
occur. In these cases, however, the feeling of weight, heaviness, 
and discomfort in the sigmoid or rectum is still present, and there 
is more or less tenesmus, and an unsatisfied feeling after stool. 

In women, pressure from a large impaction on the uterus, or 
ovaries, may cause anterior displacement and symptoms of uterine 
irritation. Through direct pressure and renexly, the bladder be- 
comes irritable, and frequent micturition results. Patients suf- 
fering from impaction usually present, in addition to the forego- 
ing, symptoms of autointoxication, such as dizziness, headache, 
coated tongue, foul breath, indigestion with or without vomiting, 
abdominal distention, lack of ambition, and general malaise. 

DIAGNOSIS 

The diagnosis is not difficult. By rectoabdominal palpation, the 
round, or often nodular, mass can be made out in the lower left 
inguinal region, or in the rectum itself. To the examining finger 
in the rectum, it may be hard and nodular, or, owing to its being 
in a pouch or diverticulum and almost completely surrounded by 
mucous membrane, it may give an impression of being an extrarectal 
pelvic tumor. 

On direct examination with the proctoscope with the patient in 
the knee-shoulder position, and the rectum inflated, the impaction 
can be easily made out. It is important in using the proctoscope 



108 DISEASES OF THE RECTUM 

to carefully manipulate the instrument so as to see behind each 
rectal valve, as not infrequently the pouching occurs in any of these 
locations, and the contained impaction, or concretion, is almost com- 
pletely hidden from sight. If palpation discloses a mass in the 
sigmoid flexure, examination with the sigmoidoscope may be em- 
ployed to demonstrate the impaction or concretion to the eye. It 
is important to determine by either ocular inspection, or examina- 
tion with a sound, whether we are dealing with an impaction of 
clay-like consistency, or a hard concretion, as the treatments of the 
two are necessarily somewhat different. 

TREATMENT 

The treatment of this condition consists in the prompt removal 
of the impacted mass. Situated in the rectum and reached by the 
finger, it may be easily broken up without the use of any instru- 
ment, providing it is of recent origin and its consistency not firmer 
than stiff clay. When it is situated beyond the reach of the finger, 
or if of too firm a consistency to be easily manipulated, the injec- 
tion of 8 or 10 fluid ounces of liquid petrolatum, olive oil, or cotton- 
seed oil, with the patient in the knee-shoulder position, and this 
allowed to remain for 12 hours, will often so soften and disintegrate 
the mass that it can be passed without any difficulty. In many cases 
this will bring the impaction down so low into the rectum that it 
can be broken up with the finger or a dull spoon curette used 
through the proctoscope, with the patient either in the lateral or 
lithotomy position. 

The most reliable method is, however, the injection of peroxid 
of hydrogen in solutions varying in strength from 10 to 25 per cent. 
With the patient in the lateral position 2 to 4 ounces of peroxid 
solution are injected through a soft-rubber rectal tube inserted up 
to the impaction. The tube is allowed to remain in place, and at 
the end of 5 minutes the rectum irrigated, when it will be found 
that the impacted mass has been disintegrated through the mechan- 
ical action of the liberated gas and is easily washed out. Several 
injections of the peroxid solution may be necessary, but if persisted 
in, it may be relied upon to do the work. When the mass is of long- 
standing and so hard that it takes on the characteristics of a true 
concretion, it may become necessary to dilate the sphincters under 



FECAL IMPACTION 109 

local anesthesia and to break up the mass with a short- jawed litho- 
tribe passed through an operating-sized proctoscope. When the 
concretion is larger than 1% inches in its widest circumference it is 
safest and best to administer nitrous oxid, dilate the sphincters, 
crush the concretion, and remove the mass with forceps. 

After the impaction has been removed, the patient should be put 
on a liquid, absorbable diet for two or three days. Liquid petrola- 
tum should be administered in doses of one or two teaspoonsful 
four times daily, and regular daily defecations encouraged. The 
atonic condition of the rectum should be overcome by the use of the 
author's pneumatic massage bag, as outlined in the chapter on the 
treatment of chronic constipation. 



CHAPTER VI 

PRURITUS ANI 

Pruritus ani is the most annoying symptom, short of pain, which 
may accompany any disease of the rectum or anus. It is because 
of the intense suffering and discomfort which it causes, when pres- 
ent, that it has been given the prominence and importance that is 
accorded it of treating it as if it were a disease by itself. 

Pruritus ani, which may be an accompanying symptom of so 
many different diseases, in reality should not be considered alone 
as a disease any more than rectal pain or rectal hemorrhage. Like 
constipation, however, it is such an important symptom, and often 
the only apparent symptom of some diseased condition, that it has 
been thought wise to emphasize it in this chapter, and to speak of 
some of the conditions which most frequently cause it. 

CAUSES 

Pruritus ani may be caused by or accompany every known anal 
or rectal disease, as well as many diseases affecting other organs or 
general in character. In other words, it may be caused by: 

1. Any disease of the rectum or anus. 

2. Any skin disease affecting the anal region. 

3. As a reflex from diseases of the bladder, prostate gland, uterus, 
ovaries, vagina — in fact, any part of man's or woman's urogenital 
apparatus. 

4. General or constitutional diseases. 

5. Dietary disturbances. 

6. Parasites. 

7. Irritation from clothing, detergents, or moisture. 

The discussion of the various anal and rectal diseases which 
present pruritus ani as a symptom will be taken up in the respective 
chapters devoted to those diseases. The skin diseases most com- 
monly affecting the anal region are marginal eczema, herpes, ery- 
thema, scabies, and folliculitis. 

110 



PRURITUS ANI 



111 



Stone in the bladder is not infrequently accompanied by an itch- 
ing of the anus and perineum. Chronic prostatitis, vesiculitis, ure- 
thritis, phimosis, and cystitis may also be accompanied by itching 
of this region. Any disease of the uterus or adnexa may cause itch- 
ing in the region of the anus, and many times the symptom of pru- 
ritus is caused by some irritating discharge from the vagina. 

Pediculi, threadworms (Oxyuris vermicular is), itch-mite (Acarus 
scabei), ringworm (Trichophyton) , are the most common parasites 
manifesting their presence in the anal region by itching. 




Fig. 65. — Pruritus ani. Characteristic cracking around the margin of the anus and at the 
posterior commissure, and the area of irritation of the apposing surfaces of the buttocks. 



Among the diseases of a more general character which are fre- 
quently found to be the causes of itching at the anus are : diabetes, 
malaria, uric acidosis, nephritis, tuberculosis, syphilis, and hysteria. 
Many patients suffer from an attack of pruritus ani after partaking 
of alcoholic stimulants in excess. The adoption of national prohi- 
bition will soon cause this etiologic factor, at least, to disappear. 
In others, the excessive use of tobacco, coffee, tea, and spices also 
conduces to the production of this symptom. Some patients are 



112 



DISEASES OF THE RECTUM 



subject to attacks of pruritus aui only during the strawberry season, 
while others have an attack every time they partake of sea foods, 
particularly of the shellfish variety. Some patients possess an 
idiosyncrasy toward some one food or class of foods, and it is the 
indulgence in this class only which brings on an attack of pru- 
ritus ani in these particular individuals. 

In many cases itching is caused by mechanical irritation of the 
skin surrounding the anus or by the use of coarse or harsh material 




Fig. 66. — Pruritus ani, showing excoriation of anterior and posterior commissures. 

in cleansing the anus after defecation. Some writers claim that the 
printer's ink on newspapers acts as a special irritant to the anus. 
The wearing of underwear colored with dyes of inferior quality, 
as well as the pressure of clothing which fits too snugly in the peri- 
neal region; the irritation caused by excessive sweating, particu- 
larly in stout individuals, and those who are forced to work in a 
high temperature, such as engineers, stokers, molders, and gas 
workers, are often responsible for the production of pruritus ani. 
Personal uncleanliness in this region is too often found to be the 
cause of pruritus, as in other parts of the body. 



PRURITUS ANI 113 

There has been a condition described by some writers as idio- 
pathic pruritus ani, because of the presence of itching of the anus 
alone as the symptom, and the discovery of no other apparent cause 
for its existence. I do not believe that there is such a thing as 
idiopathic pruritus ani. I have seen cases in my practice where 
after the most painstaking and thorough search no cause could be 
found for the itching; yet I believe there was a local cause, only it 
was not discovered. The fact that some of these cases are cured 
empirically by stretching of the sphincter muscles would seem to in- 
dicate that there might be some local condition irritating the nerve- 
endings which was mechanically relieved by the stretching process. 
A perineuritis of the anal nerves is undoubtedly present, either as 
a primary or secondary factor in many cases of pruritus ani. Most 
cases of pruritus ani will be found to accompany a proctitis, which 
may involve a small circumscribed area or the whole proctal lining. 

D. H. Murray, of Syracuse, believes that the cause of all cases of 
pruritus ani will be found in an infection from the Streptococcus 
fecalis, and has made extensive studies to support his views. He 
has reported in several communications to the American Procto- 
logic Society a large number of cases cured by the use of autog- 
enous vaccines made from the Streptococcus fecalis. 

The author has verified Murray's claims as to the presence of this 
organism in practically every case of pruritus ani, but has been un- 
able to secure the same success in the vaccine treatment. The 
therapeutic methods to be described in this and subsequent chapters 
have been followed by such success that they will not be aban- 
doned until something more specific is presented. 

DIAGNOSIS 

The appearance of the anus and perineum in the patient suffer- 
ing from pruritus ani is quite characteristic — the skin around the 
anus being thrown into numerous, deep folds radiating from the 
anal orifice (Fig. 65). In those cases accompanied by more or less 
moisture, the skin is white, soggy, and more or less macerated, with, 
here and there, small raw areas where the skin has been denuded 
of epithelium by scratching. In other cases of not so long-stand- 
ing, we find the skin around the anus normal in color but dry with 
a tendency to scale. The cutaneous folds are not so deep, but in 



114 



DISEASES OF THE RECTUM 



the sulci are found small cracks in the skin and extending up into 
the mucous membrane. In many cases, particularly in stout in- 
dividuals, a long raw fissure or crack may be found extending along 
the median raphe anteriorly to the scrotum or posteriorly into the 
median perineal crease for a distance of from one to four or five 
inches. The skin surrounding the anus and these various cracks 
may be reddened and excoriated for a great distance from the 




Fig. 67. — External integumentary hemorrhoids accompanied hy pruritus ani. This shows 
the extent to which cutaneous irritation may go, in this case extending up over the sacrum 
and down nearly half-way to the knees. 



lesion (Fig. 66). It may extend some distance up on the abdomen 
or down the thighs (Fig. 67) and legs to the knees. In cases of long- 
standing the skin surrounding the anus loses its elasticity and be- 
comes hard, thick, and leathery. This condition is in reality due 
more to the scratching, rubbing and infection by the patient in his 
futile efforts to relieve the condition than to any pathological con- 
dition brought about by the itching itself. 



PRURITUS ANI 115 

Pruritus ani may mean anything from a slight feeling of un- 
easiness or irritation in the anal region to an intense burning, 
almost crazing, itching characteristic of the most aggravated types. 
There are several" things characteristic about this itching: 

1. It is usually more intense at night. 

2. It tends to become progressively worse. 

3. It is not relieved by scratching. 

4. In spite of the fact that the sufferer soon realizes that the 
scratching or rubbing only aggravates the condition, he persist- 
ently and constantly continues to scratch. 

While every disease affecting the rectum or anus may be re- 
sponsible for the production of pruritus ani, those that most com- 
monly cause it are fissure of the anus, ulcer, particularly of the anal 
canal, anal fistula, either complete, incomplete, or burrowing, hyper- 
trophied papillae, diseased crypts, and proctitis. The reader is re- 
ferred to the respective chapters describing these conditions with 
their diagnosis and treatment, The presence of the Streptococcus 
fecalis in every case must be taken into consideration, but, in the 
majority of cases, as an agent of secondary infection. 

Every case of pruritus ani demands the most careful investiga- 
tion into the patient's habits, occupation, and mode of living, as 
well as the most thorough examination of the anus, rectum, sigmoid, 
and adjoining organs. 

Unfortunately in some few cases where pathologic conditions 
have been found in the anus or rectum, which were thought to be 
the cause of pruritus ani, their removal has not relieved the itching. 
In fact, on account of the healing by granulation and the resultant 
scar tissue, some cases have been reported in which the itching has 
been aggravated. It is important, therefore, to be very guarded 
in the prognosis and not promise a cure. 



TREATMENT 

The treatment of pruritus ani is of course the treatment of the 
disease, whether local or general, which causes it; and the reader 
must use his general medical knowledge in the treatment of diseases 
of a constitutional nature and in the treatment of the general dis- 
eases mentioned above, as that does not come within the scope of 



116 DISEASES OF THE RECTUM 

this work. The treatment of the symptom, itching, must be simply 
palliative, while the treatment of the condition which is responsible 
for the itching is being carried out. If due to any of the rectal or 
anal diseases mentioned herein, follow out the treatment as laid 
down in the various chapters. If due to any skin disease of the 
part, such as marginal eczema, consult any good work on derma- 
tology and treat it as you would any other skin disease in any part 
of the body. The author has found the following ointment a most 
successful one in these cases : 

P* Pulveris calamine 3ii 

Zinci oxidi 3i 

Hydrargyri chloridi mitis gr. xv. 

Phenolis TITxx 

Adeps lanre hydrosi . §i 

Misee et fiat unguentum. 

This is applied freely to parts, after cleansing and thoroughly 
drying, after each bowel movement and at night. In some cases 
where there is considerable moisture the following powder may 
be used instead of the ointment: 

P* Chloretone gr. xxx 

Pulveris calamine 3i j 

Zinci oxidi 3 j 

Hydrargyri chloridi mitis gr. xxx 

Misee et fiat pulvis. 

This is applied in the same manner as the ointment. 

Herpes and erythema of the skin surrounding the anus may be 
relieved by the application of the compound stearate of zinc with 
balsam of Peru or stearate of magnesia. The parts must be pro- 
tected, and the surfaces kept from rubbing against each other by 
absorbent cotton. Sometimes ordinary corn starch acts as a very good 
protective powder and certainly prevents and relieves chafing. 
Scabies is best treated by the ordinary sulphur ointment of the 
pharmacopoeia. Where inflammation of the hair follicles exists 
with the formation of pustules, they must be opened, washed 
with a 25 per cent solution of peroxid of hydrogen, and then 
dressed with a compress of any of the standard antiseptic solu- 
tions, boracic acid being used by the author. Where the Pediculi 
pubis are present, liberal applications of blue ointment or tincture 



PRURITUS ANI 117 

of larkspur should be used. In ringworm the Trichophyton may be 
reached by sulphur ointment. Where threadworms are present, 
lime-water enemata will very quickly relieve. They should be in- 
jected twice daily, using from 4 ounces to % P^t at each sitting, 
and capsules containing one-half grain calcium sulphid, given three 
times daily before meals. 

In cases where excessive indulgence in smoking, alcoholic stimu- 
lants, and articles of diet that produce or aggravate itching is re- 
sponsible, it is obvious that these indulgences must be interdicted. 
Where the occupation or habits are at fault, changes are necessary 
in order to bring about the best results. The remedies or combina- 
tion of remedies which are recommended for pruritus ani are many. 
Blackwash is recommended by many authorities as an old reliable 
remedy. Tuttle considered carbolic acid in ointment, or solution 
from 5 to 20 per cent, as the most generally applicable of all drugs 
for the relief of pruritus ani. He recommends this prescription : 

I* Phenolis 3ii 

Acidi salieylici 3i 

Glycerini 3i 

Misce secundem artem. 

Sig. : Apply to the parts with camel's hair brush or cotton swab softened in 
hot water. 

Cripps recommends : 

I£ Phenolis 3ss 

Unguenti hydrargyri 3ii 

Unguenti petrolei §i 

Another ointment of which he speaks very highly is 

I£ Extracti eonii 3i 

Olei ricini 3i 

Unguenti lanolini q. s. ad %\ 

Cripps recommends a lotion containing two grains of bichlorid of 
mercury to the ounce of lime water as an application after thor- 
oughly washing the parts with soap and water. 

Gant recommends as a hard ointment the following: 

IJ Phenolis gr. xx 

Mentholis i gr. x 

Camphors gr. x 

Sevi H 

Misce. 
Sig. : Apply freely two or three times daily after cleansing the parts. 



118 DISEASES OF THE RECTUM 

In the preparation of the above he advises to melt the suet 
and when partly cooled to add the other ingredients. He espe- 
cially cautions against adding oil, as the ointment should be quite 
hard, the object being to form a coating over the parts which 
will not be penetrated by the secretions. Citrine ointment (un- 
guentum hydrargyri nitratis) is highly recommended by Gant in 
cases where it is necessary to restore the circulation, and the indurated 
skin to its normal color and suppleness. Through the sugges- 
tion of Dr. L. H. Adler, Jr., Gant uses it in the following man- 
ner: After the parts have been bathed in warm water, the citrine 
ointment (which may have to be weakened in some cases by the 
addition of lard) should be spread on several thicknesses of gauze, 
applied, covered with oiled silk, and held in place by a snug T- 
bandage. This ointment should be kept on constantly, or in some 
cases it may be found necessary to alternate it with an ointment 
containing 20 grains of calomel to an ounce of petrolatum. 

In the author's experience for the mere relief of itching, com- 
presses or enemata of water as hot as can be borne have given 
the greatest relief in the greatest number of cases. Sometimes 
cold acts better than hot. An ointment containing 25 per cent of 
chloretone in white cold cream has proved very efficacious in the 
author's hands for the same purpose. 

In cases presenting a fissured condition of the anus, skin, and 
mucous membrane, the application of 100 per cent solution of 
nitrate of silver will cause a desquamation of the entire surface 
within 24 hours. Then a 5 per cent scarlet-red ointment in 
vaselin is applied on alternate days. The use of a mechanical 
vibrator, with a cone-shaped vibratode, for five minutes at a time, 
using from 5,000 to . 7,000 strokes a minute, and inserted as far 
as can be borne by the patient, will often afford much relief. 
Firm pressure by means of a hard-rubber rectal plug affords re- 
lief to some individuals where all other measures have failed. 
It must be borne in mind that, while any of the remedies men- 
tioned herein are being used to relieve the itching, they are but 
palliative, and the permanent relief of the itching comes only 
after the diagnosis and cure of the condition which causes it. 
This must be diagnosed and studied for treatment; and if the 
condition is not amendable to non-surgical treatment or operative 



PRURITUS ANI 119 

treatment under local anesthesia, it is more likely a case for the 
proctologist than for the general practitioner, and his aid should 
be called in. 

If the itching is caused by the discharge from rectal cancer or 
from the small, shallow ulcerations of the mucous membrane be- 
tween the sphincters — which Wallis, of London, claims is the cause 
of 90 per cent of all cases of true pruritus ani — then the indicated 
surgical procedures should be carried out, whereupon the itching 
will be relieved. In all cases where the Streptococcus fecalis, de- 
scribed by Murray, is found, the administration of autogenous 
vaccines should be tried, along with the measures advocated above. 

The writer would suggest that one should carefully read over 
the chapters on proctitis, constipation, anal fissure and ulcer, fistula, 
hemorrhoids, and hypertrophied papillae, as well as the chapter on 
the examination of the patient, before attempting to treat a case 
presenting pruritus ani as a symptom. 

In many cases the local condition seems to imperatively demand 
surgical treatment, and in many of these patients prompt relief is 
experienced after the indicated operation. The author describes 
below those which he can safely recommend. 

Surgical Measures. — In those cases of pruritus ani in which the 
skin surrounding the anal orifice has been hypertrophied and 
thrown into heavy folds and the sulci between these folds fissured, 
eroded, and giving forth an irritating discharge, a simple surgical 
procedure will often give relief. The removal of these hypertro- 
phied skin folds under local anesthesia will give very good results. 

Where there are only two or three folds involved, they can all 
be removed at one sitting. Otherwise, the operation may have 
to be done at different sittings, with intervals between long enough 
to allow of complete healing of the ones already operated on. 
There is no reason why in the average case the whole operation 
cannot be completed at the time. 

After cleansing, shaving, and sterilizing the parts, the patient 
is placed in either the lithotomy or lateral position. Each fold 
to be removed is injected from its outermost point with % per 
cent solution of apothesin or % to % per cent solution of eucain 
lactate. After allowing three to five minutes for the anesthetic 
to take full effect, the fold is removed by grasping its apex with 



120 DISEASES OF THE RECTUM 

a pair of forceps and cutting' it out at its base with a sharp scis- 
sors curved upon the flat, or by elliptical incisions with the scalpel. 
The other fold or folds are treated in like manner, and the wound 
surfaces allowed to fall together without suture; and they usually 
heal by first intention. The bowels are kept confined for two days, 
and then moved by the administration of a heaping teaspoonful of 
compound licorice powder on the evening of the second day, fol- 
lowed the next morning by a six-ounce oil enema. Applications 
of a 5% solution of silver nitrate to the wound surfaces 
daily will greatly hasten healing. After two or three weeks 
another two or three folds, preferably those situated opposite to 
those previously removed can be treated in a like manner, and 
the same technic carried out until all the redundant tissue has 
been removed. 

Where the pruritus is most persistent at the posterior com- 
missure of the anus, and examination at that point shows either 
nothing but a thickened and irritated area extending a short way 
into the anal canal, or shallow excoriations at the anal margin 
which are neither fissures nor true ulcerations, the removal of a 
kite-shaped flap of skin and mucosa at this point is often followed 
by relief from the symptoms. 

The technic is as follows : 

After cleansing, shaving, and sterilizing the parts, a point three 
quarters of an inch behind the posterior commissure is selected, 
and ] /{> per cent solution of apothesin, % per cent solution of 
eucain lactate, or % per cent solution of quinin and urea hydro- 
ehlorid, injected so as to include a triangle whose apex is the point 
of injection and whose base extends from one-quarter to one-half 
inch to either side of the posterior anal commissure. The infiltra- 
tion of the anesthetic solution should extend up into the anal canal 
far enough to include any excoriated or irritated areas. A tri- 
angular flap of skin is dissected up by means of a sharp scalpel 
or sharp-pointed scissors curved on the flat — starting at the point 
of injection and extending to the posterior margin of the anus. 
The incisions then should be brought toward each other so as to 
meet at a point one quarter of an inch above the diseased area 
in the anal canal. The latter part of the operation makes a short, 
broad triangle, whose base is the same as the base of a longer one 



PRURITUS ANI 



121 



on the skin surface. This leaves a denuded kite-shaped area. The 
skin is brought together by three or four No. 1 or 2 chromicized 
catgut sutures, boro-chloretone powder applied, and the wound 
protected with a gauze pad held in place by adhesive strips (Fig. 
68). The care of the bowels is the same as that outlined above, 
and the after-treatment consists of daily cleansing of the parts and 
reapplication of boro-chloretone, or compound stearate of zinc 
powder. Healing will take place in from four to seven days, and 
the relief experienced by the patient after this procedure in se- 
lected cases is very satisfactory. 




Fig. 68. — A simple and satisfactory rectal dressing, consisting of a gauze-covered cotton 
pad and two strips of adhesive plaster. 

Ball's Operation. — One of the most successful surgical measures 
available for employment under local anesthesia, for the relief of 
persistent pruritus ani, is the ingenious operation devised by Sir 
Charles Ball, of Dublin. 

As described in Ball's work on "The Rectum," its employment 
is advocated under general anesthesia. The author, however, has 
been able to perform an improved modification of the operation 



122 



DISEASES OF THE RECTUM 



with brilliant results by the employment of local anesthesia. The 
object of the operation is for the purpose of dividing all the sensory 
nerve-twigs supplying the skin of the anus, anal canal, and cir- 
cumanal region, which arise from branches of the third and fourth 
sacral nerves, come down to the levator ani muscle, and reach the 
skin by perforating the external sphincter. 




Fig. 69. — Sharp-pointed scissors curved on the flat. 




Fig. 70. — T-forceps.. 

Sometimes a small submucous or submuco-cutaneous fistula (Fig. 
99-4) leading from a Morgagnian crypt will be found to be the cause 
of a localized pruritus. If so, it should be removed according to 
the technic outlined in Chapter IX. 

The technic as employed by the author is as follows : 
The patient is given a hypodermic injection of % grain of 
morphin and % 50 grain of hyoscin and is placed in the left lateral 
or Sims position, and the area surrounding the anus cleansed, 
shaved, and sterilized. 



PRURITUS ANI 



123 



An ounce of y 8 per cent solution of beta-eucain lactate, or Y 2 
per cent solution of apothesin, or the same quantity of % per 
cent solution of quinin and urea hydrochloric!, should be prepared 
and in readiness. Ten or twelve sharp-pointed curved needles, 
each threaded with No. 2 chromicized catgut; a couple of sharp, 
small-bladed scalpels ; sharp-pointed scissors curved on the flat 
(Fig. 69) ; two pairs Pennington triangular (Fig. 109) or of T- 
forceps (Fig. 70), and two or three hemostats ; and the syringe for 




Fig. 71. — Ball's operation for pruritus ani. Elliptical lines of incision on either side of 

the anus. 



injecting the solution are all the instruments required. Selecting 
the point about one-half inch behind the posterior extremity of 
the lines of incision in Fig. 71, the skin and subcutaneous tissue 
are infiltrated. From this point the area, included inside the 
lines in Fig. 71 and for one-half inch beyond, is distended until 
complete anesthesia is secured up to the anorectal juncture. The 



124 



DISEASES OF THE RECTUM 



presence or absence of skin sensibility to pain should be tested 
before starting to operate. The incisions, as outlined in the above 
illustration, are then made with a sharp knife down through the 
skin to the subcutaneous tissue. The area included between the 
lines of incision should be of elliptical shape, and about twice 
as long in the antero-posterior direction as it is broad in the lateral, 
with the anal canal as its center. With the patient in the left 
lateral position, the incision on the left side is made first, the inner 
flap of skin is grasped with triangular or T-forceps, and by rapid 




Fig. 72.— Ball's operation for inveterate pruritus ani. Method of dissecting the flaps 
and of dividing the terminal cutaneous nerve-twigs, which, for the purpose of clearness, are 
somewhat exaggerated in the drawing. — After Ball. 

and careful dissection with the scalpel is raised from the surface 
of the external sphincter muscle and freed up to the anorectal 
juncture. The anterior and posterior pedicles between the ends 
of the incisions are freed from the subcutaneous tissues as well. 
In other words, all connections between the funnel-shaped cutaneous 
and mucocutaneous covering of the anus and anal canal are freed 
entirely from their underlying tissues (Fig. 72). Ball advocates 
the use of the scissors for this work, but the author has found he 



PRURITUS ANI 



125 



can work much more rapidly and with more assurance of dividing 
all the sensory nerve-twigs by the use of a sharp scalpel. All 
bleeding should be controlled by pressure with dry gauze, and the 
flaps sutured again to the surrounding skin with silkworm or No. 
2 chromicized catgut. Four to six interrupted sutures are all that 
are necessary for each incision. Firm pressure by wedge-shaped 
gauze pads is brought to bear against the region operated on, and 




Fig. 73. — Ball's operation for pruritus am. The crossed lines show the area to which the 
wound is undercut, and the outside limits of anesthesia produced by the operation. 



the dressings held in place by adhesive plaster and a T-bandage. 
This operation, by dividing all of the sensory branches supplying 
the area most often involved, immediately renders this region su- 
perficially anesthetic, and the pruritus is relieved at once (Fig. 73). 
Cutaneous sensation returns after a few months, but pruritus is per- 
manently relieved. 

Louis J. Krouse, of Cincinnati, has modified this operation by 
substituting six or eight radiating incisions for the elliptical ones 



126 



DISEASES OF THE RECTUM 



used by Ball (Fig. 74). His technic possesses the advantage of 
less possibility of interference with the circulation and vitality of 
the flaps, and suturing is usually not required. 

After-Treatment. — The after-care consists in keeping the pa- 
tient on an absorbable liquid diet and keeping the bowels confined 
for four or five days, when they are moved by a soapsuds or oil 
enema. The parts are carefully washed and kept protected at all 




Fig. 74. — Krouse's radiating incisions for his modification of Ball's operation. 



times by the liberal use of compound stearate of zinc or magnesia 
powder. The patient should be kept in bed for a day or two and 
then allowed to be up and about, but not to resume his regular oc- 
cupation for five or six days. In the experience of the author, the 
results following this operation have been most happy, partic- 
ularly in those old chronic cases where all other forms of treat- 
ment have been tried and found wanting. 



CHAPTER VII 

ANAL FISSURE AND ULCER 

Anal fissure, or fissura in ano, is probably responsible for more 
acute pain, suffering, and discomfort than any other lesion of its 
size occurring in the human body. The fissure, as its name im- 
plies, is a crack or elongated ulceration, occurring most frequently 
at the posterior commissure of the anus (Figs. 75, 76, 77, 78.) 




Fig. 75. — Typical site of anal fissure. 



CAUSE 

Fissures are caused by trauma. The traumatism may be pro- 
duced by passing an unusually large stool, introducing or expel- 
ling a foreign body, straining, sneezing, coughing, or by faulty 
instrumentation. Fissures usually occur singly. When more than 

127 



128 



DISEASES OP THE RECTUM 



one is present it is an evidence, as a general rule, of the presence of 
tubercular, gonorrheal, or syphilitic infection, or a run-down con- 
dition caused by some of the wasting diseases (Fig. 79.) 

In men, in 90 per cent of the. cases, the fissure will be found 
in the vicinity of the posterior anal commissure; in women, in 
about 60 per cent — the other location being in the region of the 
anterior commissure. 

The reasons for the posterior commissure being the most fre- 
quent location for fissure are: The fact that on account of the 




Fig. 76. — Traumatic fissure. 



concavity of the sacrum the curvature of the rectal and anal canal 
is' such that the greatest force during the expulsion of the stool 
is toward the posterior commissure ; also, the fact must be remem- 
bered, that some of the fibers of the sphincter ani muscle run 
parallel to each other posteriorly (Fig. 4) to the coccyx, and this 
is the direction of the anal line of cleavage. Moreover, this is a 
constant location for one of the crypts of Morgagni, and the tear- 



ANAL FISSURE AND ULCER 



129 



ing-down of a semilunar valve at this point (Fig. 80) is often the 
starting-point in the production of fissure. 

Any inflammatory condition which will cause a moisture and 
softening of the anal skin will render it more liable to be injured 
during a movement and fissure produced. A fissure is, in reality, 
an infolded longitudinal ulcer. When the fissure has been in ex- 
istence for some time, it tends to become chronic, the tissues sur- 




Fig. 77. — Anal fissure with sentinel pile. 



rounding it become indurated, and the skin is pushed down in the 
form of a tag which becomes hypertrophied (Figs. 77, 78 and 80) 
in such a way as to form a thick crescentic fold known as the 
"sentinel pile." Fissures are frequently found accompanying 
hemorrhoids, the ulceration being located in the sulcus between 
two hemorrhoidal masses. Not infrequently, when the fissure is 
of the chronic variety, it is accompanied by a polyp, which, by 



130 



DISEASES OF THE RECTUM 



hanging down into the fissure from its upper extremity, tends 
to keep it irritated and prevents it from healing. One reason 
advanced for the fact that fissures or ulcerations in the anal canal 
tend to become chronic rather than to heal is the fact that the 
anal canal is lined by a layer of thin transitional epithelium, which 
is neither mucous membrane nor skin, and is poorly supplied with 
blood. This fact, and the action of the sphincters, keeping the parts 
in motion, tend to prevent good healing. 




Fig. 78. — An aggravated case of anal fissure, showing sentinel pile. 



DIAGNOSIS 

The diagnosis of fissure is comparatively easy. A patient, pre- 
senting himself with a history of sharp, cutting, often excruciat- 
ing pain, accompanying the passage of a hard stool, and the ap- 
pearance of hemorrhage, usually slight, following the passage, is in 
itself almost pathognomonic of a fissure. Added to this, the history 
of pain, usually very severe, as well as the appearance of blood with 
each succeeding stool, is corroborative. When the patient also com- 
plains of a beating, throbbing pain, lasting from half an hour to 



ANAL FISSURE AND ULCER 



131 



several hours following the passage, and painful spasmodic con- 
tractions of the anal sphincter, or pruritus ani, the diagnosis of 
anal fissure is without an examination almost conclusive. How- 
ever, one can never take the diagnosis of any condition in the 
anal or rectal region for granted, without making a thorough ex- 
amination. Therefore, after obtaining such a history, the patient 
should be placed on the table in the lateral position for examina- 
tion. 




Fig. 79. — Multiple anal fissure. 



Upon separating the buttocks, the first thing that will usually 
attract attention, except in acute cases, is the presence of a sen- 
tinel pile. This gives a clue at once to the location of the fissure, 
which will be found, as above stated, just at either side of or at 
the posterior anal commissure. Inasmuch as the entire sphincter 
is inflamed, hypertrophied, and exquisitely sensitive to the touch, 
it may be necessary, before a satisfactory examination can be made, 
to, anesthetize the parts. 

However, if by gentle traction on the skin, just below the sentinel 



132 



DISEASES OP THE RECTUM 



pile, an abrasion is disclosed, extending upward into the anal canal, 
the diagnosis of fissure is confirmed. If this procedure causes 
the patient much suffering, it had better be abandoned until the 
sphincter has been anesthetized according to the technic outlined 
in Chapter XV. 

In cases which have existed for some time, the fissure, instead 
of presenting a red angry appearance, may be covered with a 
grayish or yellowish exudate. The reason that a fissure or ulcera- 




Fig 80. — Anal fissure resulting from the tearing-down of one of the crypts of Morgagni 
with the formation of a sentinel pile. 



tion of this region is so exquisitely tender is because of the ex- 
posure of some of the numerous nerve-endings with which this 
area is so generously supplied. The only other condition with 
which fissure is liable to be confounded is hemorrhoids, and that 
only from the patient's standpoint. Not infrequently, practi- 
tioners have been led into the error of taking the patient's word 
for the fact that he Avas suffering from hemorrhoids, because of 
the symptoms of pain at stool and hemorrhage; therefore the author 
would reiterate, at the risk of becoming tiresome, that a rectal 



ANAL FISSURE AND ULCER 



133 



examination must be made in every case, when the exact diagnosis 
can be easily made. 



TREATMENT 

The treatment of anal fissure resolves itself into palliative and 
operative. Some cases of fissure of recent origin are entirely 
amenable to non-surgical treatment. The first thing to do is to 
relieve constipation, which is done by putting the patient on a 
suitable diet, excluding all articles which leave much residue and 
cause bulky stools. The administration of white petroleum oil, 
suitably flavored, in doses of from one-half to one ounce daily, 




Fig. 81. — Method of applying ointment to the anus from a long-nozzled collapsible lead tube. 

will soften the stools to such an extent as to make them easy of 
expulsion, though not liquid and irritating. 

Where the fissure is shallow, and is not accompanied by the 
formation of a sentinel pile, the application of a swab moistened 
in 2 per cent eucain solution, for four or five minutes, followed 
by the application of pure ichthyol to the surface of the fissure, 
is very efficacious. This is repeated every second day. In the 
meantime the patient is instructed to carefully cleanse the parts 
after bowel movements and to apply, by means of a long-nozzled 
ointment tube (Fig. 81), the following: 



134 



DISEASES OF THE RECTUM 



3£ Chloretone gr. xxx 

Thymolis iodidi gr. xx 

Ichthyoli gr. xxx 

Adeps lanes hydrosi q. s. ad §ss 

Misce et fiat unguentum. 

Occasionally, where the fissure is very superficial and consists 
merely of a crack in the mucous membrane, a single application 




Fig. 82. — Application of carbolic acid at point of puncture. 

of a saturated solution of nitrate of silver will be sufficient. This 
acts by causing a protective covering of albuminate of silver to 
be formed and effects the cure. Proper attention to the condi- 
tion of the bowels, cleanliness, and the application of stearate of 
zinc powder are all the after-care that is required. 

The daily applications of mild solutions of nitrate of silver, 



ANAL FISSURE AND ULCER 



135 



alum, copper sulphate, or the use of the caustic stick are not to 
be advised, because they only keep up the irritation and destroy 
the new granulation tissue as fast as it is formed. The stronger 
solution of silver nitrate, as mentioned above, by its sudden coagula- 
tion of the albumin of the tissues when it comes in contact with 
the wound, causes the formation of an impermeable protective 
covering for the granulating surface beneath, and moreover, is far 
less painful than the milder solutions. The application of 5 per 
cent scarlet-red ointment every third day is an excellent stimulant 
to the formation of new epithelium. Suppositories for the relief 




Fig. 83. — Injection of anesthetic for excision or fissurectomy at usual site. 



of fissure do not appeal to the author; inasmuch as fissure is always 
found in the anal canal and the action of a suppository is exerted 
only in the lower rectal cavity, he fails to see where any direct 
relief can be obtained from suppositories in this condition. More- 
over, it is doubtful whether an ointment applied with the finger 
is of any value, for it certainly cannot be applied high enough 



136 



DISEASES OF THE RECTUM 



to reach any but the most dependent portion of the fissure ; yet 
it is astonishing how often the patient suffering with fissure is 
dismissed with a prescription for an ointment. 

Surgical Treatment. — The best, surest, and quickest treatment 
for anal fissure is incision or excision. The author knows of no 
operative procedure in the practice of proctology from which more 
satisfactory results are achieved than the incision or excision of 
an anal fissure. Under local anesthesia, this is very easily and 




Fig. 84 — Injection of anal fissure at the base of its sentinel pile at the anterior commissure. 

readily accomplished, and the results are invariably all that could 
be desired (Figs. 82 et seq.). 

Incision. — The technic of incision of anal fissure is as follows: 
After anesthetizing the sphincter and dilating it, as outlined in 
the chapter on local anesthesia, a dram of % per cent solution 
of apothesin, y 8 per cent solution of eucain, or % per cent solu- 
tion of quinin and urea hydrochlorid, is injected below and around 
the fissure in such a way as to raise it up so that it is resting 
on a "water-bed." After waiting at least five minutes for anes- 



ANAL FISSURE AND ULCER 



137 



thesia to become complete, an incision is made from the extreme 
upper end of the fissure down through the center and extending 
beyond the lower extremity for a quarter of an inch into the skin 
(Fig. 87). The incision should be so made that its upper or inner 
extremity will be the shallowest, and it should become deeper until 
at the lower or skin end it is from one-quarter to one-half inch 
in depth, slanting in such a way that the upper or shallowest part 
will be the first to heal and the lower the last — thus providing ex- 




Fig. 85. — Anesthesia and sphincteric relaxation complete, giving excellent exposure for 

fissurectomy. 

cellent drainage. The unhealthy surface should be swabbed with 
tincture of iodine, a suppository containing two grains each of 
chloretone and thymol iodid, or ten grains of quinin and urea hydro- 
chlorid, inserted, and a single strip of plain gauze may or may not 
be placed in the wound. 

At the end of 24 hours the gauze is removed, but the patient's 
bowels are not allowed to move for two or three days at least. In 
the meantime, he is kept on liquid diet, and the administration of 



138 



DISEASES OF THE RECTUM 



white petroleum oil is started on the evening of the second day, 
so that the first stool will be soft and unirritating. It is advisable 
on the evening before a stool is desired to administer a level tea- 
spoonful of compound licorice powder, and the first thing the 
following morning, to inject through a small rubber catheter six 
or eight ounces of soapsuds or olive oil into the rectum to insure 
a soft and easy moment. 

The after-care consists in keeping the parts clean, the bowel 
movements soft, and the patient up and about after the first 24 




Fig. 



-Fissure grasped ready for excision. 



hours. If granulations become flabby or unhealthy in appearance, 
a single application of saturated solution of sulphate of copper 
or of nitrate of silver is usually sufficient to stimulate healthy 
healing. On the other hand, if the patient is in a rundown con- 
dition and the healing slow, the insertion of a one-half -inch strip 
of gauze soaked in bovinine, twice daily, will nourish the healing 
tissues and bring about a speedy result. Scarlet-red ointment, 5 
per cent, is also of great value in these sluggish cases. 



ANAL FISSURE AND ULCER 



139 



While in many cases this procedure will be sufficient, it will 
not answer where the fissure is of long-standing, or if surrounded 
by an area of infiltration, or where there is a well-developed sen- 
tinel pile, or a polyp accompanying the fissure. Often a fissure 
after incision will not heal, because of the fact that the mucous 
membrane dips down into the wound and tends to keep its edges 
apart. To obviate this, and to make sure that all the diseased 
tissues are removed, the author excises instead of incises, when 
operating for chronic anal fissure. 

Author's Operation. — With the patient prepared and anes- 
thetized as for the incision operation (with the exception that 




Fig. 87. — Simple incision of fissure 



ight posterior lateral quadrant of anus. 



the area of infiltration anesthesia is made more extensive so as 
to include all the induration surrounding the fissure), he proceeds 
as follows : 

The fissure is grasped at its upper extremity with sharp-toothed 
forceps (Fig. 88), and two longitudinal incisions are made, one 
on either side of the fissure, starting from one-eighth to one- 
fourth inch to either side of its upper or inner extremity, and 
being made in such a manner that they meet underneath the 
fissure in its median line, forming a V-shaped trench (Fig. 90), 
which is one eighth of an inch deep at its upper extremity and 



140 



DISEASES OF THE RECTUM 




Fig. 88. — Sharp-toothed or pronged forceps. This is a very useful instrument in many 
anorectal operations, and while originally designed as a tonsil forceps, is of great value in 
proctologic work. 




Fig. 89. — Anal fissure complicating internal hemorrhoids. 



one fourth of an inch wide ; and at the outer or skin portion its 
width is from one half to three fourths of an inch and its depth 



ANAL FISSURE AND ULCER 



141 



from one-fourth to one-half inch. This disposes of the entire 
fissure, with its indurated edges, and the sentinel pile as well. 
It also allows the fissure to heal quickest at the bottom and pre- 
vents any overgrowth of the mucous membrane or dipping-down 
of the edges. If a polyp is situated at the upper extremity, the 
incisions are carried up to include it ; and as the fissure is dissected 
up from below, a ligature is thrown around the base of the polyp, 
tied, and the fissure and polyp cut away en masse. The after- 




A B 

Fig. 90. — Author's technic for the excision of chronic anal fissure. 

A. The dotted lines show the line of incision both on skin surface and mucous membrane. 

B. Showing V-shaped bed left after removal of the flap containing the fissure; the 
dotted lines show the shape and the direction of the incision inside of the anus. 



treatment is the same as outlined for the incision operation. This 
operation, in the hands of the author, has been so satisfactory 
that it is his routine treatment for all chronic and many extensive 
acute fissures not amenable to non-surgical treatment. Occasionally 
in both acute and chronic fissures of a mild type, the simple removal 
of the sentinel pile has sufficed to effect a cure. 



142 



DISEASES OF THE RECTUM 



ANAL ULCER 

Whatever has been said of anal fissure in regard to treatment 
by non-surgical measures is equally applicable to anal ulcer, the 
only distinction between the two conditions being a question of 
the shape of the ulceration— the fissure being elongated, while 
the other ulcers of the anus are round or irregular in outline. 
In ulcers which do not respond to the applications advocated for 
fissure, the injection of a few drops of % P er cen t eucain solu- 




Fig. 91. — Posterior anal ulcer. 



tion, or 1 per cent of quinin and urea hydrochlorid, under the 
ulcer is advisable, and a light curetting of its surface will often 
be followed by marked relief. Where the ulcer is of long-stand- 
ing, the excision of the indurated tissues surrounding, as well 
as the ulcer itself, should be accomplished, fallowing the same 
technic as outlined for the excision of fissure, varying the direc- 



ANAL FISSURE AND ULCER 



143 



tion of the incisions to correspond to the shape of the ulcer (Figs. 
91-92.) 

The after-treatment following excision of an anal nicer is exactly 
the same as that, outlined above, following fissure. It is the watch- 
ful after-care of the conscientious physician, following many of 
these minor anal operations, which is responsible for the good 




Fig. S2. — Operation for excision of anal ulcer. Xote the manner in which the incisions are 
brought to a point at tipper and lower extremities of wound. 

results — for often a well-executed operation is nullified in its re- 
sults by neglectful, slovenly, or misdirected after-care. Oftentimes 
the after-care of patients following these operations is overdone 
rather than the reverse, and meddlesome interference accomplishes 
more harm than the operation does good. 



CHAPTER VIII 

ABSCESS OF THE ANORECTAL REGION 

The region of the anus and rectum is peculiarly prone to in- 
fection and abscess formation, for several reasons: The unusual 
amount of cellular tissues surrounding the rectum; the lavish 
blood supply of this region; the constant presence in the rectum 
of pyogenic bacteria; the traumatism from, unusually large or hard 
feces; foreign bodies, such as spicules of bone, fruit pits, seeds, 
and other articles which have been ingested. The rich lymphatic 
supply of this region is of great importance in the production 
and extension of septic inflammation. Skin diseases around the 
anus, particularly those which affect the hair follicles, inflammation 
of external hemorrhoids, the irritation from clothing or harsh 
detergents, disease of the crypts of Morgagni, rectal ulceration 
and anal fissure — all may form the starting-point for the formation 
of an abscess in this region. 

Septic infections of the anorectal region have been divided into 
different classes by different authors. Tuttle classifies them as 
follows: 



Circumscribed 
inflammations 
or abscesses. . 



Superficial 



Profound 



Subtegumentary 

Tegumentary 

Ischiorectal 

Retrorectal 
Superior pelvirectal 
Interstitial 



Diffuse inflammations 



Diffuse perirectal cellulitis 
Gangrenous perirectal cellu- 
litis 



Of the circumscribed inflammation or abscesses, only those which 
are located below the levator ani muscle are amenable to treat- 
ment under local anesthesia, and will be considered by the author 



144 



ABSCESS OF THE ANORECTAL REGION 



145 




Fig. 93. — Anorectal abscesses. 

Submucous or intermural abscess. 
Ischiorectal abscess. 
Marginal or subcutaneous abscess. 
Tegumentary or cutaneous abscess. 



under the head of tegumentary or perineal abscesses; perianal, mar- 
ginal, or subtegumentary abscesses; submucous or intermural; and 
ischiorectal abscesses (Fig. 93.) 

TEGUMENTARY ABSCESS 

The tegumentary, or perineal, abscesses are really nothing more 
than pustules, or furuncles of the skin surrounding the anal orifice, 
or a pustular inflammation of the hair follicles. They may be 



146 DISEASES OF THE RECTUM 

brought about by anything which causes irritation of the parts, such 
as extensive perspiration, discharge from the anus or vagina, chafing 



, -- '- 



«v 



Fig. 94. — Circumanal ulceration, infective. (Note undermining due to circumanal abscesses.) 

from the clothing, infection by the finger-nails in scratching, per- 
sonal uncleanliness, or the use of harsh detergent materials. The 



ABSCESS OF THE ANORECTAL REGION 147 

condition may range from a simple acne of the parts to the for- 
mation of numbers of typical furuncles or boils. These cause a 
slight sense of irritation, smarting or itching, and cause more dis- 
comfort when the patient is sitting or walking than any inter- 
ference with the function of the bowel itself. Occasionally sev- 
eral of these small abscesses may run together, forming a typical 
carbuncle. This, however, is rather rare in this region. There 
is usually a slight rise of temperature, a degree or two at the 
outside, and more or less irritability of the patient's temper. There 
are no constitutional symptoms. 

Diagnosis. — With the patient in the lateral posture, these ab- 
scesses will be seen occurring either singly or in groups as rounded 
reddened swellings from the size of a large pinhead to a hazel 
nut, with or without a point of suppuration showing in its center. 

Treatment. — The treatment consists of spraying each abscess 
with ethyl chlorid and opening with a sharp bistoury. After al- 
lowing the pus to escape, the cavity is swabbed with 95 per cent 
carbolic acid. Daily washing of the part with warm saturated 
solution of boracic acid and dressing with boro-chloretone powder 
will usually be all that is necessary in the line of after-treatment. 
The parts should be washed after defecation and protected with 
sterile gauze, and the clothing worn loose so that there is no 
pressure or chafing from that source to keep up the irritation. 

If there is a tendency for these little skin infections to recur, 
it is advisable to treat the patient with a bacterial vaccine made 
from the predominant germ responsible for the infection. In 
most cases this will be found to be the Staphylococcus pyogenes 
aureus or albus. 

SUBTEGUMENTARY OR MARGINAL ABSCESS 

The most common abscess developing in the region of the anus 
is that which occurs deeper under the layers of the skin or lining 
membrane of the anus, described in the above classification as 
subtegumentary, also known as perianal or marginal abscess — 
also as subcutaneous, submucous, or intramural, depending upon 
the kind of tissue under which the abscess develops. While often 
their starting-point can be traced to a fissure or ulcer, infection 
of the bloodclot of a broken-down thrombotic pile, or a diseased 



148 



DISEASES OF THE RECTUM 



crypt, or the traumatism due to a bit of bone or other swallowed 
foreign body, nevertheless, in many cases, the point of infection 
cannot be determined. This leads us to the conclusion that the ab- 
scess is caused by extension through the lymphatic system, from 
some more or less remote injury or disease in this region. They 
may occur at any age, but are less common in children. 




Fig. 95. — Characteristic sitting posture assumed by patients suffering from anorectal disease. 



Symptoms. — Occasionally, abscesses which occur in this re- 
gion, particularly the submucous variety, have developed to a 
considerable size without causing any other symptoms than a sense 
of uncomfortableness or fulness in the lower rectum, noticed par- 
ticularly during defecation. Usually, however, the patient com- 



ABSCESS OF THE ANORECTAL REGION 149 

plains first of sharp darting pains in the rectum, which are soon 
followed by an aching, throbbing pain which is persistent and 
gradually increasing. This aching extends to the sacral region, 
and the pain often shoots down one or both legs, even to the heel. 
The patient often complains of difficulty of urination. Defecation 
is always painful, and on account of the feeling of fulness in the 
rectum, is deferred by the patient as long as possible. The pulse 
rate increases in rapidity, and the temperature rises from one to 
four degrees. The patient cannot sit comfortably and rests his 
weight on either buttock — a characteristic posture of patients suf- 
fering from acute rectal disease (Fig. 95), which in itself is almost 
diagnostic. 

An abscess may often develop in from 24 to 36 hours, and oc- 
casionally will rupture before the patient is really aware of the 
severity of the trouble. These are the cases with terminate in the 
formation of fistulas. 

Examination. — With the patient in the lateral posture, often 
nothing can be determined by ocular inspection unless the abscess 
be situated at or outside the margin of the anus, when it will 
appear as a rounded swelling, reddened in color, situated usually 
at either side of the posterior anal commissure. On digital exam- 
ination, it can be definitely outlined, and its extent determined. 
If seen early, a definite point of fluctuation cannot be made out, 
but the whole abscess has a hard, doughy feel. It is extremely 
tender on palpation, and on account of the accompanying spas- 
modic contraction of the sphincter muscle, it is often very hard to 
examine. 

Treatment. — The treatment of the subcutaneous or marginal 
variety is very satisfactorily accomplished under local anesthesia. 
If the abscess is situated at or below the juncture of the anus 
and rectum, it will not be necessary to anesthetize the sphincter 
muscle. With the patient in the lateral or lithotomy position, 
the parts are scrubbed, shaved, and sterilized, and the skin over 
the abscess injected with a % P er cen "t solution of apothesin or 
% per cent solution of beta-eucain lactate. A point one-half inch 
below the abscess proper is selected for the first injection, and 
the injection carried upward so that a wheal or welt a quarter 
of an inch to half an inch wide, and extending the entire length of 



150 DISEASES OF THE RECTUM 

the abscess, is formed. After waiting fully ten minutes for the 
anesthetic to take effect, an incision is made from one extreme of 
the abscess to the other in a direction at right angles to the anus, 
and the pus allowed to escape. It is then irrigated with sterile 
water or normal salt solution, and after breaking down any di- 
viding walls, so as to convert the abscess into one cavity, it is 
swabbed out with equal parts of tincture of iodin and carbolic 
acid; a light gauze drain inserted, and a sterile dressing applied. 
When the author says lightly inserted, he means the gauze should be 
inserted sufficiently firm to keep the wound edges well separated and yet 
touching against the lining of the cavity so lightly as not to interfere 
with its contraction during the healing process. The patient is not 
allowed to arise from the table for five or ten minutes after the 
operation, when he is slowly assisted to his feet, and after a few 
minutes in a chair will be able to go on his way. 

It is advisable to keep the patient on an absorbable diet for a 
couple of days and not allow the bowels to move during that 
time. The wound should be dressed daily, being irrigated with 
Carrel-Dakin or any of the other chlorinated solutions, the value 
of which was so well demonstrated during the recent World War. 

In the author's experience in an army base hospital in France, 
it was found that the use of Carrel-Dakin 's solution, dichloramine-T 
and flavine materially hastened healing in every case. In a fair 
percentage of cases, secondary suture was successfully performed. 

At the end of the third or fourth day in the average case all 
drainage can be discarded except a strip of gauze inserted merely 
to keep the wound edges apart. This must be renewed daily as 
long as any purulent discharge persists. The best protective pow- 
der to use to keep the discharge from irritating the surrounding 
skin is compound stearate of zinc with balsam of Peru or mag- 
nesium stearate. 

SUBMUCOUS ABSCESS 

The submucous or intermural variety occurs underneath the 
mucous membrane covering the lower rectum, and may be found 
at any point in the circumference of the rectum. Those located 
in the anterior wall are usually accompanied by disturbances of 
urination. In fact, oftentimes patients are unable to urinate at 



ABSCESS OF THE ANORECTAL REGION 



151 



all and have to be catheterized. This variety is diagnosed by digital 
examination — the well-lubricated finger gently inserted through 
the anus while the patient is asked to bear down. A rounded 
mass may be felt within an inch or inch and a half of the anal 
outlet, either of a doughy consistency or distinctly fluctuating. By 
gently sweeping the finger from side to side, the outlines can be 




Fig. 96. — Proctoscopic view of submucous abscess of the rectum. 



made out, and its extent determined. With the short anoscope, 
the diagnosis can be further confirmed (Fig. 96), and not infre- 
quently the point of infection determined. Occasionally, the ab- 
scess may extend down to the integument beyond the anus, form- 
ing: a submucocutaneous abscess. 



152 DISEASES OF THE RECTUM 

Diagnosis. — The diagnosis, after both digital and ocnlar ex- 
amination, is very evident. Given the symptoms of rise in tem- 
perature, rapid pulse, aching, throbbing, pain coming on more or 
less suddenly in the region of the aims or lower rectum and re- 
maining, becoming more persistent and increasing in severity, 
with the presence of a circumscribed painful swelling, these make 
the diagnosis of abscess in this region conclusive. 

Treatment. — When the abscess is of the submucous variety 
and situated above the internal sphincter, it will be necessary to 
anesthetize the sphincter, according to the technic outlined in 
Chapter XV. After washing out the rectum with saturated solu- 
tion of boracic acid, the patient is placed in either the lithotomy 
position, if the abscess is situated on the anterior wall, or the 




Fig. 97. — De Vilbiss rectal specvdum. This instrument is useful in many anal opera- 
tions, on account of the fact that its blades may be opened parallel to each other and it 
can be self-retaining. 

lateral position, if located on the posterior or lateral wall. After 
the parts are washed, shaved, and sterilized and the sphincter 
anesthetized, it is slowly dilated, and a single Sims retractor 
inserted at a point opposite the abscess and held by an assistant. 
In the absence of an assistant, a De Vilbiss rectal speculum (Fig. 
97) will answer, as it is self -retaining. The mucous membrane 
covering the abscess is injected with a Y 2 per cent solution of 
apothesin or a % per cent solution of eucain lactate, or % P er 
cent solution of quinin and urea hydrochlorid, until the tissues 
are blanched over the entire abscess. 

After waiting five minutes for the anesthetic to take effect, the 
abscess is opened by a longitudinal incision extending from its 
extreme upper end down Avell below its lower extremity. The 
pus is alloAved to drain out, when the cavity is irrigated with 
normal saline solution or sterile water. All dividing walls are 



ABSCESS OF THE ANORECTAL REGION 



153 



broken down so that the abscess is converted into one cavity. 
It is then swabbed ont with 95 per cent carbolic acid or eqnal 
parts of carbolic acid and iodin, and gauze lightly inserted, which 
should extend out through the anus. In some cases it is advis- 
able to insert a rubber drainage tube about the size of a lead 
pencil, which tube should extend an inch outside the anal canal. 
The after-care is similar to that advised for the subcutaneous 
variety, especial care being taken to see that the abscess is kept 




Fig. 98. — Line of incision for opening an ischiorectal abscess. 



healing from the bottom, and that no ramifications form during 
the healing process. The patient is allowed to be up and about 
immediately after the operation, and is properly kept up on ac- 
count of better drainage in the upright position. It is this variety 
of abscess which, if allowed to open without surgical interference, 
forms the internal sinus or blind internal fistula. It is an im- 
portant thing to remember, in this form of abscess particularly, 
that the incision should be carried well below the lower extremity 
of the abscess, so as to allow good drainage. 



154 DISEASES OF THE RECTUM 



ISCHIORECTAL ABSCESS 



Ischiorectal abscesses are the most extensive variety which can 
be treated under local anesthesia, and not all of these, by any 
means, are favorable cases. The author would lay down the rule 
that no abscess of the ischiorectal region ivhose upper extremity is 
over two inches from the anal skin, and whose extent, size, and loca- 
tion cannot be definitely outlined by bimanual palpation, should be 
operated unless under a general anesthetic. 

Ischiorectal abscesses start, grow, and extend with great rapid- 
ity on account of the loose cellular tissues, in which they form, 
offering little or no resistance to their spread. They occur at 
either side of the rectum, and occasionally surround it. They are 
caused by either the puncture of the rectal walls by spicules of 
bone, bristles, or other ingested foreign substances, or from dis- 
eased Morgagnian crypts or infection which is carried by the 
lymphatic system. They have been known to follow operations 
on the rectum and anus, or injury caused by faulty instrumenta- 
tion in making a rectal examination. 

Symptoms. — The constitutional symptoms are similar to those 
which accompany the subcutaneous or submucous abscesses, with 
the exception that the pain is more deeply seated, the sacral ach- 
ing more severe, and the symptoms in general approaching more 
nearly those of a general septic infection. The patient often 
suffers from chills, with a high fever, severe headaches, backache, 
fetid breath, languor, loss of appetite, and more or less prostra- 
tion. The pain localizes itself on either side of the rectum, unless 
there is a simultaneous infection on both sides. Defecation is 
so painful that the patient gives up all attempts at it and fre- 
quently also is unable to urinate. If the abscess has existed 
longer than 48 hours, some redness of the skin will be observed, 
varying in degree according to the nearness of the abscess to 
the integument. 

Diagnosis. — Bimanual rectal palpation, with one finger in the 
rectum and the other hand pressing toward it just outside the 
anus (Fig. 98), will disclose a hard elongated mass, often pear- 
shaped, which is extremely painful, and gives the characteristic 
doughy or boggy feeling of an abscess. A point of fluctuation 
oftentimes can be made out at the loAver extremity of the abscess. 



ABSCESS OF THE ANORECTAL REGION 155 

The diagnosis is readily made on bimanual examination. The 
swelling caused by the abscess may be so great that it is prac- 
tically impossible to introduce the proctoscope into the rectum. 

Treatment. — After the rectum has been flushed with a satu- 
rated solution of boracic acid, the patient is placed in the lithotomy 
or lateral position, according to the location of the abscess, and 
the parts washed, shaved, and sterilized. The sphincter is an- 
esthetized, according to the technic outlined in Chapter XV, and 
the skin over the abscess, as well as the anal lining membrane, is 
infiltrated with a % per cent solution of apothesin, % per cent 
solution of eucain lactate, or a % per cent solution of quinin and 
urea hydrochlorid. After the infiltration of the skin, the sub- 
cutaneous tissues down to the abscess are injected with the quinin- 
urea solution, care being taken not to penetrate the abscess cavity 
with the hypodermic needle. The infiltration should be carried 
well into the lower rectum. A single Sims retractor (Fig. 109) 
is inserted at a point opposite the abscess and held by an assistant, 
or the De Vilbiss speculum used, and opened to its fullest extent. 
With a sharp-pointed bistoury an incision is made from the outer- 
most point of the abscess on the skin toward the anus, so that the 
incision is at right angles to the anal canal. The opening should 
be made wide enough so as to thoroughly drain the abscess cavity, 
and only if necessary, should be extended through the sphincters 
into the anus. 

Where the abscess cavity can be well exposed by an incision 
which stops short of the sphincter and there are no ramifications 
of the cavity, it will not be necessa^ to enter the rectum, and 
the author, as a rule, would caution against making an opening 
in the rectum unless a communication already exists in the form 
of a fistula. All trabecule and partition walls should be broken 
down so that the abscess is converted into a single cavity, and 
it should be irrigated with saline solution or sterile water. The 
incision at the outermost point of the abscess cavity should be as 
wide or wider than the cavity itself. After irrigating the cavity 
sufficiently, gauze soaked in balsam of Peru should be gently in- 
serted so as to keep its walls apart. A dressing is applied, and 
the patient advised to keep in the recumbent position, lying prefera- 
bly on the operated side for 24 hours. 



156 DISEASES OF THE RECTUM 

At the end of that time, the packing is removed, and about 
two thirds of the quantity of gauze used in the first dressing 
lightly inserted. At each succeeding daily dressing the amount 
of gauze is lessened until the abscess cavity has healed up from 
the bottom. If the granulations become flabby or unhealthy at 
any time, they should be touched with a saturated solution of 
copper sulphate or a 25-100 per cent solution of silver nitrate. The 
application of pure ichthyol every second or third day, while 
somewhat painful, is of extreme value in promoting good granu- 
lation. 

Where it has been found necessary to carry the incision into 
the rectum and sever the sphincters, care should be taken to 
arrange the drainage in such a way as to prevent the skin or 
mucous membrane from growing down into the wound, and pre- 
venting the reuniting of the sphincter as the abscess cavity heals. 

If this should happen, however, in spite of all precautions, anes- 
thetize the part by the application of a swab soaked in 4 or 5 per 
cent eucain solution for five minutes, keeping up pretty steady 
pressure on the parts. Then with a pair of sharp-pointed scis- 
sors, curved on the flat, trim back all redundant tissue to the sur- 
face of the skin or mucous membrane as the case may be. 

In the treatment of all suppurative conditions of the anorectal 
region, the author would caution his readers to refrain from 
attempting to operate on any case in which there is the slightest 
doubt of his ability to complete the operation under local anes- 
thesia. One must be sure of the size, location, and extent of the 
abscess, and it must be definitely outlined and definitely circum- 
scribed in order to be amenable to treatment under local anes- 
thesia. 



CHAPTER IX 

ANAL FISTULA— ANAL SINUS 

A fistula may be described as a tubular suppurating tract, com- 
municating" with or connecting the mucous membrane of the anus 
or rectum, and the integument contiguous to the anal outlet. 




Fig. 99. — Anorectal fistulse and sinuses. 

Internal sinus. 

External sinus. 

Complete direct fistula. 

Submucous or submucocutanecus fistula. 

157 



158 DISEASES OF THE RECTUM 

Fistulas are of several different varieties, which will be described 
below. A fistula is the result of an abscess in the anal region, 
which has either been untreated and allowed to rupture, or when 
opened by the surgeon has, through insufficient, careless, or im- 
proper after-treatment, been allowed to contract without being 
made to heal from the bottom. The only exception would be 
a fistula caused from a punctured wound, either traumatic or 
surgical. 

Anal fistula is often spoken of as either tubercular or non- 
tubercular. While the author realizes that tuberculosis is a factor 
to be seriously considered in the discussion of fistula, he will re- 
serve his remarks on this particular variety of fistula until farther 
on in the chapter. What is said regarding fistula below, therefore, 
must be understood to mean the non-tubercular varieties. 

The reason that an abscess degenerates into a fistula in this 
region, rather than to completely heal, is due to two factors 
peculiar to its location. The most important is the fact that, due 
to the natural motion of the anus and rectum in the act of ex- 
pulsion of gas or feces, and the dilatation and contraction of the 
sphincter muscles, the parts are not allowed to remain at rest, 
and the surfaces are prevented from adhering to each other. Added 
to this is the important fact that mucus and feces enter the abscess 
cavity from the rectum and their constant passage tends to keep 
the tract open and prevent healing. A fistula, therefore, is in 
reality the tubular contracted remains of an abscess, and is lined 
by a pyogenic membrane as was its parent abscess. 

VARIETIES OF FISTULA 

The variety of a fistula depends on the location and kind of 
abscess which preceded it. They are divided by some authors 
into complete and incomplete. A complete fistula is one which 
gives a direct communication between the bowel and the surface 
of the skin, somewhere in the region of the anal opening. An 
incomplete fistula is either one which has an opening into the 
bowel alone or one which opens through the integument alone. 
Complete fistulas (leaving out of consideration those which com- 
municate with other organs, such as the bladder, vagina, or urethra) 
are divided into horseshoe fistulas and multiple fistulas. The horse- 



ANAL FISTULA ANAL SINUS 159 

shoe fistula is characterized by its having one opening in the anal 
canal, usually situated between the sphincters at the posterior com- 
missure, and surrounding the anus, communicates with the skin 
by two openings — one on each side of the anus. A multiple fistula 
is one which has one or more internal openings and numerous 
branching channels opening by many external openings on the skin. 

The incomplete, or so-called "blind," fistula is in reality a sinus. 
The term "blind fistula" should, therefore, be discarded, as sug- 
gested by Pennington in favor of the more truly descriptive term 
"sinus." We, therefore, speak of internal sinus and external sinus, 
whether anal or rectal, instead of blind fistula. The internal sinus 
opens on the mucous membrane, while the external sinus opens on 
the skin. 

A form of fistula known as the submucous fistula is one which 
has two openings, both opening on mucous membrane, and is 
usually found just inside the anal canal. The most common lo- 
cation for the internal opening of a fistula is at the posterior com- 
missure of the anus and between the sphincter muscles. In this 
chapter only those varieties of fistulas which are amenable to treat- 
ment under local anesthesia will be discussed: viz., simple com- 
plete fistula, external sinus, internal sinus, and submucous (Fig. 
99). 

SIMPLE COMPLETE FISTULA 

This is the commonest form of fistulas met, and is the remains 
of a subcutaneous or ischiorectal abscess, and consists of a straight 
or slightly curved channel running from the anal canal or some 
point in the rectum a little higher up to the outside skin — usually 
opening within one or two inches of either side, and below the 
anal aperture. The internal opening is usually posterior, between 
the sphincters; it may, however, be found at any point of the anal 
circumference. The external opening may be at any point on 
the skin in the vicinity of the anus, but the points mentioned are 
the usual sites. 

Symptoms. — The symptoms are a sense of irritation or an itch- 
ing of the anal region, pain during defecation, and the presence 
of a purulent discharge. If for any reason one of the openings 
should become plugged up, there is some distention, and pain from 
pressure. 



160 



DISEASES OF THE RECTUM 




Fig. 100. — Direct complete anal fistula. The probe is seen entering the external or cu- 
taneous opening, while directly above it its blunt-tipped extremity is seen emerging from 
the anus. 




Fig. 101. — Angular fistulous tract. The upper portion of the fistula has been opened, 
and the probe can be seen entering the lower portion. The end of the probe can be seen 
emerging from the left upper quadrant of the anus. 



ANAL FISTULA ANAL SINUS 



161 



Diagnosis. — The diagnosis of fistula should always be in mind 
when on examination of a patient a papule is seen on the peri- 
neum or buttocks, from which a drop of pus exudes or can be 
pressed out. This is the characteristic appearance of the external 
opening of a fistula. With the patient in the lateral position 
and the index finger of one hand over the external opening, the 
index finger . of the other should be inserted with the palmar 
surface directed toward the posterior commissure. Often by the 
pressure with the finger in the rectum a drop of pus will be forced 
out through the external opening. By carefully feeling the region 
between the anal canal and the outside opening, one will often 
make out the cord-like feel of the fistulous tract. Oftentimes the 
internal opening is extremely difficult to find. Upon examination 
with the author's fenestrated anoscope, or the anoscope with the 




Fig. 102. — Best type of glass syringe for injecting bismuth paste into fistulous openings. 

oblique aperture, a small reddened spot, often raised somewhat 
from the surface, will be detected, from which pus can be squeezed 
out. When this point is discovered digital examination will reveal 
the induration underneath the surface, which discloses the direction 
of the fistulous tract. If, after careful examination of the entire 
circumference of the anal canal and lower rectum, no internal 
opening can be detected, the injection into the external opening 
of peroxid of hydrogen, (Figs. 102-3) methylene-blue solution, milk 
of magnesia, or bismuth paste will assist one in locating the in- 
ternal opening by the point of appearance of the solution inside 
the anus or rectum. 

The probe may be used to diagnosticate the presence and direc- 
tion of a fistulous tract, but in order to be of any value, it must 
be very fine and extremely pliable — one made of annealed-silver 
suture wire is the best for this purpose (Figs. 27, 107, 109C). One 



162 



DISEASES OF THE RECTUM 



must be extremely careful in introducing a probe into a fistulous 
tract, or sinus for it is very easy to force it through its walls 
into the anal canal or rectum, thus creating a false passage. If the 
probe does not pass easily, it is better to discard it than to use any 
force in its use. If there is a suspicion that the fistula communi- 
cates with the bladder or urethra, the injection of. a mild solution 
of methylene blue 1 to 5 per cent into the organ will settle the 
question. If such a communication be present, the colored solu- 
tion will exhibit itself at the fistulous opening in very short order. 




Fig. 103. — Injection of fistulous tracts with bismuth paste. 



A five-grain capsule of methylene blue administered by mouth will, 
if a communication with the bladder or urethra exists, show a blue 
discoloration of the fistula in a few hours. The injection of a warm 
paste made from one part of bismuth subnitrate and two parts 
of vaselin into the external opening of a fistula, followed by a 
stereoscopic radiograph, is, without doubt, the best and most ac- 
curate diagnostic agent in our possession today. The existence of 
tracts, otherwise undiscoverable, is thus demonstrated, and the op- 
eration can be definitely planned in advance (Figs. 104-106). 



ANAL FISTULA ANAL SINUS 



163 



Treatment. — The treatment of fistula, as a general thing, is best 
accomplished under general anesthesia, because many times, upon 
laying open what appears to be a simple fistulous tract, ramifica- 
tions and extensions may be found which would necessitate more 
dissection than is possible to accomplish satisfactorily under local 
anesthesia. A case of simple, direct fistula, however, which is not 
tortuous, and in which the whole channel with its external and 




Fig. 104. — Radiograph of simple direct complete fistula. 



internal opening is made out by the diagnostic methods mentioned 
above, may be treated under local anesthesia in any one of three 
ways. 

Incision. — Simple incision will suffice in some cases where the 
fistula is not deeply seated. After the bowels have been washed 
out with a saturated boracic-acid solution and the area around 
the anus scrubbed, shaved, and sterilized, the sphineter is anes- 



164 DISEASES OF THE RECTUM 

thetized, according to the technic outlined in Chapter XV, and 
the tissues over the fistula injected to the point of blanching with 
Y 2 per cent solution of apothesin or a % per cent solution of eucain, 
or 1 per cent solution of quinin and urea hydrochlorid. A soft 




Fig. 105. — Complicated complete fistula. This ran up nearly six inches behind the rectum. 
Its branching channels would have been missed had it not been for the radiograph. 

silver wire probe is passed through the fistula, its internal end 
drawn outside the anus by forceps, and twisted around the external 
end (Fig. 113). This threads the fistula on the probe, Avhen it is 
released by dividing all the tissues between the wire and the 



ANAL FISTULA ANAL SINUS 



165 






surface by a curved bistoury passed from without inward. This 
frees the probe and lays open the entire fistula. A pledget of 
cotton soaked with a 2 per cent solution of eucain or apothesin 
is pressed into the incision and is held firmly against the opened 




Fig. 106. — Multiple fistula communicating with urethra. This case had twelve external 
openings besides the one into the urethra. 

fistulous tract for two or three minutes. It is then removed, and 
the diseased surface lightly curetted with a sharp spoon curette, 
the incision loosely packed with gauze, and an anodyne supposi- 
tory inserted and a dressing applied. 



166 



DISEASES OF THE RECTUM 



Unless the direction of the fistulous tract is in a line at right 
angles to the fibers of the sphincter muscle, it must not be opened 
by a single straight incision. It is an invariable rule that any 
incision which must sever any or all of the fibers of the sphincter 
should cross it only at right angles (Fig. Ill) in order to prevent 
incontinence afterward. The incision, therefore, must be so di- 
rected that it never severs the sphincter muscle in an oblique 




Fig. 107. — Soft silver probe passed through posterior direct complete fistula. 

manner. Where the fistula is located just below the skin or mucous 
membrane and does not involve the sphincter, this rule does not 
necessarily hold good. 

Excision. — In some cases it will be found advantageous, in- 
stead of simply opening the fistulous tract, to excise the entire 
canal. This is the most satisfactory operation when it can be 
successfully carried out, and should be the operation of choice 



ANAL FISTULA ANAL SINUS 



167 



in all straight, uncomplicated fistula? which are situated so that 
the tissues surrounding the fistula can be successfully infiltrated. 
After the usual preparation of the patient and anesthetization 
and dilatation of the sphincter muscles, the tissues surrounding 
the fistula are anesthetized. A % P er cen "t solution of apothesin 
or a % per cent solution of eucain is injected into the skin along 
the line of incision up to the opening in the anal canal; then the 
surrounding tissues are distended with a Y 2 per cent solution of 
quinin and urea hydrochlorid, care being taken to completely sur- 
round the fistula on all sides. A silver wire is then inserted as 
described in the operation of incision, and the ends, which have 
been brought together outside the anal opening, are twisted so that 
they pull the whole fistulous tract outside the anus. This 
brings the entire tract into view. The skin is then incised the full 
length of the fistula clown to the infiltrated tissues surrounding it, 
but not through them (Fig. 113). The incisions are then carried 
on either side of the infiltrated fistulous canal in such a way as 




Fig. 108. — Grooved director. 



to free it entirely, and remove it unopened and threaded on the 
silver wire or director. As the incisions are carried around the 
fistulous tract, they should be brought together in a V-shaped man- 
ner beneath it. After the remoA^al of the fistula, the wound should 
be loosely packed with gauze, the anodyne suppository inserted, 
and dressing applied. 

In the after-care, following both excision and incision, extreme 
care must be tcken in the daily dressing of the wound to so 
arrange the drainage that it is firm enough to retard too rapid 
granulation, and yet placed so lightly as to allow the wound to 
gradually come together. Especial care must be exercised to keep 
the skin and mucous membrane from dipping in or growing down 
the sides of the incision. If granulation does not proceed as rapidly 
as it should, the gauze packing should be soaked daily with bovinine 
before applying, or pure ichthyol or balsam of Peru should be 



168 



DISEASES OF THE RECTUM 




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ANAL FISTULA ANAL SINUS 



169 



applied daily to the granulating surfaces. Scarlet-red ointment, 
5 per cent, is also an excellent stimulant to unhealthy or sluggish 
granulations and should be lightly rubbed into the wound every 
third day. It is not necessary or advisable to use any of the an- 
tiseptic powders in the after-treatment of these cases. In many 
cases, the use of the Carrel-Dakin or other chlorinated solutions as 
irrigations will materially hasten the healing process. 




Fig. 110. — Fistula with three external openings. 



The bowels are not allowed to move for three days, after which 
daily movements are not contraindicated. 

Where it has been necessary to divide the external sphincter, 
either in part or in its entirety, there may be some temporary lack 
of full control of the bowel movements; but as the wound heals, 
control is regained so that no fear need be felt on this score. The 
patient is allowed to be up and around after the first day, and 
can pursue his usual occupation with little or no discomfort. 



170 



DISEASES OF THE RECTUM 



Ligature Operations. — In some few cases, from either the desire 
of the patient that no cutting operation be clone, or some other 
contraindication, one may occasionally accomplish the cnre of a 
simple direct fistula by means of a ligature, of linen, silk, or rub- 
ber. The author does not advise the use of the ligature in these 
cases, as he personally feels that they are never so satisfactory, 
and certainly not so quick in their results as a clean-cut surgical 
operation under local anesthesia. If the patient must have a liga- 
ture operation, the rubber ligature as used by the author in his 
operation for rectal valvotomy is to be advised, as it is quicker 
and surer in its results than silk or linen. 




Fig. 111. — Right-angled incision for simple direct anal fistula. In a simple fistula by 
which the bowel communicates with the external integument crossing the external sphincter 
in an oblique manner, the external sphincter is cut at right angles by the method outlined. 



The ligature is applied in the following manner: A fine flex- 
ible probe is threaded with the material of choice, and it is 
passed through the fistula from without inward; the point pro- 
jecting in the rectum is grasped with forceps and is pulled through 
and outside of the anus. The ligature, if silk or linen, is then 
loosely tied so as not to constrict the parts but lightly surround 
them, and the ends are cut off. This leaves a small loop not un- 
like a seton. This is moved to and fro every day by the patient 



ANAL FISTULA ANAL SINUS 



171 



and in the conrse of three to six weeks gradually wears through, 
the fistula healing behind the ligature in the meanwhile. In some 
cases, however, this will not prove efficacious. 

Where more quick action is desired it is better to use the rub- 
ber ligature. It is passed through the fistula, threaded on a probe, 
in the same manner as the non-elastic ligatures, but when it is 




Fig. 112. — Soft silver probe passed through fistula and twisted into a loop. 

fastened with a perforated shot, it is put on the stretch (Fig. 
119). This causes so much pain and suffering for the first twelve 
hours that it is necessary to give the patient repeated doses of 
anodynes. After this period, however, there is comparatively no 
pain or discomfort until the ligature sloughs its way through, 



172 DISEASES OF THE RECTUM 

which occurs in the course of from three days to a week. The 
suffering caused by the use of this rubber ligature is far more 
intense than that experienced after one of the radical measures 
mentioned above, and the author cannot conscientiously recom- 
mend it except in those cases where other measures are refused 
by the patient. After passing the soft silver wire probe through 
the fistula, it, itself, may be drawn taut, a shot slipped over its 
ends, and it will cut through the same as the rubber ligature. If 
the wire is used, the projecting ends should be cut flush with the 
shot (Fig. 120). 

EXTERNAL SINUS 

The external sinus is caused by the opening of a perianal ab- 
scess on the skin surface only. It is characterized by the ap- 
pearance, after the rupture or opening of an abscess in this region, 
of a red spot or papule from which pus is discharging. It is ac- 
companied by discomfort to the patient when sitting, pruritus ani, 
or disagreeable moisture in the region; and its diagnosis from a 
complete fistula is made by the method of examination outlined 
above. In reality it is nothing more or less than a contracted 
abscess cavity which refuses to heal on account of the action of 
the sphincter muscle in keeping it open. 

Treatment.- — The treatment consists in the incision with curet- 
ting and drainage, or excision of the entire sinus tract. Some 
authors advise the converting of an external sinus into a com- 
plete fistula, and then operating as for complete fistula. The 
author cannot see the reason or advisability of thus converting 
a simple abscess cavity into a fistula, and would strongly depre- 
cate any such methods. The author does not believe that it is 
ever necessary to divide the sphincter in order to heal an external 
sinus. 

INTERNAL SINUS 

This variety of sinus is characterized by its having an open- 
ing into the bowel only, and is caused by the rupture into the 
bowel of a perirectal abscess whose point of least resistance was 
toward the rectum. The sinuses are characterized by their in- 
sidious and obscure onset and often go undiagnosed for a consider- 
ble time. 



ANAL FISTULA ANAL SINUS 



173 



Symptoms. — The chief symptom is the appearance of a puru- 
lent discharge from the anus. This is accompanied by some smart- 
ing, burning, or itching, and a feeling of unrest or discomfort 
in the lower rectum. If there is much involvement of the mucous 
membrane surrounding this opening, there is also a tendency to 
diarrhea. When a patient has complained of pain in the rectum 




Fig. 113. —Complete direct fistula looped on soft silver probe, showing technic of excision 

or fistulectomy. 



persisting for several days, accompanied by heat, throbbing, and 
rise of temperature; and these symptoms are more >or less relieved 
just previous to the passage of a quantity of pus from the anus — 
the breaking of a submfljoous or perirectal abscess into the rectum 
should be suspected. The continuance of a purulent discharge off 



174 



DISEASES OF THE RECTUM 



and on for a period of weeks and months means the existence of 
an internal sinns. 

Diagnosis. — With the patient in the lithotomy or lateral posi- 
tion, a roughened spot with indurated edges is felt on digital 
examination, usually posteriorly or laterally. Upon stroking or 
milking the interior of the rectum adjacent to this opening, a 
purulent discharge will be produced. Upon examination through 
the anoscope or fenestrated speculum the opening will be seen 
usually within the first inch from the anal margin. It will be 




Fig. 114. — Multiple anorectal fistulae. Note probes in openings. 



dark red in color, with edges somewhat raised, and the extent 
of the sinus can be readily determined by examination with a 
soft-silver wire probe. It is well to bend the probe on itself 
in the form of a hook, so as to determine the extent of excava- 
tion under the mucous membrane of the bowel in the direction 
of the anus, as not infrequently internal abscesses, particularly of 
the submucous variety, are found with their largest cavity extend- 
ing down toward the anus. The internal sinus is more frequently 



ANAL FISTULA ANAL SINUS 



175 




Fig. 115. — Excision of fistulous tract with wire looped through anterior tract. 




■ 



'% 



Fig. 116. — Fistulous area dissected clean. 



176 



DISEASES OF THE RECTUM 



the result of a submucous abscess than of any other variety, and its 
channel very rarely penetrates the muscular coat of the rectum. 
Treatment. — With the patient either in the lithotomy or lateral 
position and the external parts washed, shaved, and sterilized, 
the sphincter ani muscle is anesthetized and dilated according to 
the technic described in Chapter XV. Either a De Vilbiss rectal 
speculum or the anoscope with the oblique opening is inserted so 




Fig. 117. — Wound lightly packed with dry gauze. 



as to best expose the opening of the sinus. Its direction and extent 
having been determined, the tissues over the abscess and sur- 
rounding it are infiltrated with a % per cent solution of apothesin 
or % o P er cent solution of eucain, or y 2 per cent solution of quinin 
and urea hydrochlorid. A grooved director is then inserted, and 
the sinus is laid open with a long-handled scalpel, a cryptotome 
(Fig. 121), or the author's angular rectal scissors. A pledget of 



ANAL FISTULA ANAL SINUS 177 

absorbent cotton soaked with a 2 per cent solution of the anesthetic 
used is then placed in the abscess cavity and allowed to remain for 
two or three minutes. The interior of the tract is lightly curetted, 
and a strip of sterile gauze inserted for drainage, one end of the 
gauze being carried outside the anus. In laying the tract open, 
the lower extremity should be opened well down to the anus, care 
being taken to leave no pockets at the lower end. In twenty-four 
hours the gauze is removed, and a cleansing enema given. The 
bowels should be allowed to move on the third day, the stools 
being softened by the administration of liquid petrolatum, and they 
should be kept regular daily. Ordinarily these cases will heal with- 
out any further attention. It is well, however, to have the patient 
report every other day for a week or so, and to make sure that the 
cavity is healing from the bottom and the granulations are healthy. 

SUBMUCOUS TRACT, OR SINUS 

There is a variety of submucous sinus extending usually from 
the bottom of a crypt of Morgagni, which has been called by 
Wallis a submucous tract. It consists in nothing more or less 
than either an unusually small-calibered submucous sinus, or a very 
deep inflamed crypt. It gives rise to an irritating purulent dis- 
charge, which is very small in amount, but which sometimes is 
responsible for the production of pruritus arii. In order to de- 
termine its presence, it is advisable, in those cases where a dis- 
charge is noted and no internal opening of a sinus can be found, 
to examine with a probe each of the Morgagnian crypts and de- 
termine the presence or absence of one of these so-called sub- 
mucous tracts. If present, it can be slit up with a sharp-pointed 
bistoury or cryptotome (Fig. 121) after anesthetizing as outlined 
above. It requires no after-treatment, other than examination every 
other day for three or four days, to make sure that it does not heal 
over at the surface before it is thoroughly healed underneath. 

SUBMUCOUS OR MUCOCUTANEOUS FISTULA 

Cripps describes a variety of fistula very similar to the sub- 
mucous tract or sinus, which he calls mucocutaneous fistula. It 
differs from the variety just described only from the fact that 



178 



DISEASES OF THE RECTUM 



it communicates with the surface through a small opening in one 
of the anal folds instead of one of the crypts of Morgagni (Fig. 
99). 

The treatment of this variety is just the same as that just pre- 
ceding and need not be described in detail. 

INJECTION OF BISMUTH PASTE 

The use of a mixture of bismuth subnitrate and vaselin in the 
diagnosis and treatment of fistulous tracts, sinuses, and abscess 



\ ■ 

*' Hth ..ill 

: 


Ham SH^^HPt- "^" 


tfpp*. 










^ .... , 


^P^ '* 





Fig. 118. — Another case illustrating extent to which dissection must be fearlessly carried 
to get results in multiple fistulse. 



cavities, first brought out by Emil G-. Beck, of Chicago, has opened 
up an interesting field in the non-operative treatment of anorectal 
fistula. The paste recommended by Beck consists of bismuth sub- 
nitrate, 1 part, and vaselin, 2 parts. 
The technic is as follows : 



ANAL FISTULA ANAL SINUS 



179 



The patient's bowels are thoroughly irrigated, and the fistulous 
tract irrigated as well as possible. A cone-pointed glass syringe 
(Fig. 102) with asbestos packing around the plunger is filled with 




Fig. 119. — A. Technic of passing flexible silver probe, threaded with rubber ligature, 
through simple direct anal fistula. 

B. Showing method of constricting the area between fistula, anal mucous membrane, 
and skin by means of the rubber ligature drawn taut and fastened with a perforated shot. 
(See Fig. 120.) 

the mixture, which has previously been sterilized and allowed to 
cool to a temperature that will not irritate the patient. The point 
of the syringe is pressed well into the main opening of the fistula 



180 



DISEASES OF THE RECTUM 



(Fig. 103), if more than one exists, and the paste slowly injected. 
Should there be an internal opening or communication with the 
bowel, the finger of the hand not manipulating the syringe is 
inserted into the rectum to close that opening, thus preventing the 
paste entering the bowel and aiding in forcing it into all the di- 
verticuli and tortuous tracts. The same precaution is observed 




Fig. 120. — Silver wire looped through fistula and fastened with perforated shot. 



where there is more than one external communicating opening. 
The syringe is not removed as soon as the tracts seem to be filled, 
but is held firmly in position with slight continuous pressure on 
the piston. A gauze dressing and T-bandage are then applied. 
From one to five injections suffice for the average case, and they 
should be given either once or tAvice a week. Some of the au- 



ANAL FISTULA ANAL SINUS 



181 



thor's cases have required from two weeks to six months for a 
cure. While this method does not supplant the radical cure of 
fistula by operation, it should be thoroughly tried only in those cases 
where operative procedures are refused or not thought advisable. 



ANAL FISTULA IN THE TUBERCULOUS PATIENT 

The only reason that the discussion of fistula in a tuberculous 
patient is taken up among these varieties of fistula, which can be 
treated under local anesthesia, is the fact that the tuberculous 
patient is a very poor subject for general anesthesia. The ap- 




Fig\ 121. — Author's cryptotome with adjustable handle. 



parent connection betAveen fistula and tuberculosis is due to the 
fact of the tuberculous patient's resisting powers being far be- 
low par. Abscesses in the anorectal region tend to fistula for- 
mation frequently enough in those individuals who have a nor- 
mal resisting power; therefore it stands to reason that this should 
be more so in those suffering from any of the wasting diseases, 
and particularly the most common one, tuberculosis. The tuber- 
culous patient's intestinal tract is constantly flooded with tubercle 
bacilli, and an abscess cavity communicating with the bowel forms 
a covenient location for them to locate and propagate. The old 
idea that the operation for tuberculous fistula has any bad in- 



182 DISEASES OF THE RECTUM 

fluence on the patient's pulmonary condition is absolutely un- 
tenable. As a matter of fact, the local symptoms and inconvenience 
caused by the fistula make the patient much more irritable and add 
to his already overwhelming burden. 

Symptoms. — The symptoms are those accompanying anal fistula, 
as described above, the constitutional symptoms of tuberculosis be- 
ing also present. 

Diagnosis. — The only points of difference between anal fistula, 
complicated with tuberculosis, and ordinary fistula are the pres- 
ence in the discharge of Bacillus tuberculosis, and the pink, flabby- 
looking, unhealthy granulations found around the external opening. 
There is also a tendency to undermining of the skin edges and to 
silkiness of the circumanal hair. 

Treatment. — The treatment of a tuberculous fistula is the same 
as that outlined above for the different varieties of ordinary anal 
fistula, with the exception that, when the fistulous tract is laid 
open after lightly curetting, its inner surface is swabbed with pure 
lactic or glacial acetic acid. Iodoform or iodized gauze is used for 
packing and dressing on account of the peculiarly antagonistic 
effect of iodin on the tubercle bacillus. The patient should be en- 
couraged to live an out-of-door life, and his general bodily nu- 
trition and physical condition looked after the same as those of 
any other tuberculous patient. 

The injection of bismuth paste has in these cases occasionally 
proved very beneficial, and should be given a thorough trial, par- 
ticularly in those patients in whom there exists some contraindica- 
tions to surgery. 



CHAPTER X 
HEMORRHOIDS 

Hemorrhoids, which is the most common disease of the ano- 
rectal region presenting a pathological change in the tissues, is 
also the most frequently self-treated condition affecting this re- 
gion. We see more quack advertisements about, more nostrum 
remedies presented for, more irregular practitioners holding them- 
selves out to cure hemorrhoids than any other disease (with the 
possible exception of venereal disease) . In many quarters intelligent 
people, who would not think of consulting an unethical practi- 
tioner for any other condition, will consult the so-called "pile 
specialist" — who holds himself forth in the daily press — because 
they believe that members of the regular profession do not treat 
rectal diseases. It is perfectly astonishing to what an extent this belief 
is held ; in fact, the author is sorry to say that he knows of in- 
stances where members of our profession, in good standing, have 
in the past referred cases of rectal disease to advertising, so-called 
rectal specialists. 

There must be reasons for this, and the reasons are: the lack 
of instruction to the medical student on the subject of rectal 
disease, in the first place; the paucity of such instruction when 
given as an incident in the teaching of general surgery; the re- 
pugnance with which the average practitioner approaches a case 
requiring rectal examination; the cursory character of such ex- 
amination; the distaste of the average practitioner for local treat- 
ment of the anorectal region; the inability to make a correct di- 
agnosis; and the superficial treatment given and the early dis- 
charge of the patient by the practitioner, who is anxious to get 
rid of a case that is unpleasant for him to treat — all are responsible 
for the position which the average general practitioner occupies 
today in the diagnosis and treatment of rectal diseases. 

It is the action of the profession itself which has created the 

183 



184 



DISEASES OF THE RECTUM 




Fig. 122. — Interno-external hemorrhoids. 




Fig. 123. — Section of interno-external pile (photo-micrograph X4). Upon the right- 
hand side of the illustration the upper half has a covering of mucous membrane, the lower 
half a covering of skin; between these there is a sulcus, which corresponds with the pecti- 
nate line. The upper half is therefore internal pile; the lower, external pile. The struc- 
ture of the interior of both portions is practically identical — loose areolar tissue with 
dilated thrombosed veins. — After Ball. 



HEMORRHOIDS 



185 



special field of proctology — the anus and rectum being organs 
peculiar to themselves and being subject to many medical and 
surgical diseases in the same way as the eye, the ear, the nose, 
the genital and urinary organs ; and call for just as much special 
medical as surgical care. The general surgeon knows nothing 
about, and cares less for, the medical treatment of these organs; 
and the general practitioner who is able to treat the medical 




Fig'. 124. — Acute external thrombotic hemorrhoid. 



conditions is not, as a rule, properly equipped to do so. Thus, 
the proctologist came into existence— a man who, by special study 
of this particular region of the body, is able to give special care 
of either a surgical or medical nature, and often both in the 
same case, as may be required. With his attention directed par- 
ticularly to this line of work, his operative measures are directed 
largely along the lines of conservatism. He endeavors to save 



186 DISEASES OF THE RECTUM 

as much tissue as he can and cut as little as possible and by in- 
telligent after-care to promote healing much nearer to the normal, 
as a rule, than does the man who "cuts a fistula and ties a pile," 
and allows it to go at that. 

That the average general practitioner is fully as capable of 
treating many anorectal diseases as the proctologist, if he has at 
his hand a practical work outlining indicated therapeutic meas- 
ures in a plain, simple way, goes without saying. 

The treatment of hemorrhoids in the hands of the practitioner 
has undergone vast changes since special attention has been di- 
rected along this line. In many ways it has been much simplified, 
and the results have been extremely satisfactory. 

VARIETIES 

Hemorrhoids are tumors or swellings produced by pathologic 
changes in the veins of the anus and rectum, accompanied by 
more or less infiltration of the surrounding tissues and hyper- 
trophy of the anal skin. They are usually divided into three 
classes, according to location: external, internal, and externo-in- 
ternal — the external being those outside the sphincteric region and 
covered by integument; the internal being covered with mucous 
membrane, and whether situated inside the bowel or prolapsed out- 
side, they are still internal hemorrhoids. An internal hemorrhoid 
being prolapsed and remaining prolapsed will appear externally, 
but if it is covered by mucous membrane it is an internal hemor- 
rhoid. The externo-internal variety (Figs. 122-123) is a combina- 
tion of the two preceding, being covered by both mucous mem- 
brane and skin. The external, again, is divided into thrombotic, 
integumentary, and varicose. 

The thrombotic variety (Figs. 124, 125, 126, 127) usually appears 
suddenly; may range in size from a pea to a large grape; is 
rounded, of a bluish or purplish hue, and extremely painful. It 
feels much larger to the patient than it really is, and is characterized 
by its sudden onset. The integumentary variety (Fig. 128) is a 
sac or pouch of thickened skin, usually the remains of an old acute 
thrombotic hemorrhoid which has undergone absorption. The 
varicose variety consists of a collection of small varicose veins 
covered by skin and situated at or outside the anal orifice.' 



HEMORRHOIDS 



187 



The internal variety is divided into the capillary or granular, 
and the varicose. The capillary hemorrhoid may not appear as 
a tumor at all, but simply a circumscribed reddened area which 
bleeds upon touch. "Where there is an enlargement, it looks not 
unlike a raspberry. Its color is brighter than the varicose vari- 
ety, and it bleeds more freely. The varicose internal hemorrhoid 
is caused by a varicosity of the veins of the superior hemorrhoidal 
plexus, the varicose veins, together with the infiltrated tissues sur- 




Fig. 125. — Ulcerating acute thrombotic hemorrhoid. 

rounding them, forming rounded tumors of varying sizes. The 
internal hemorrhoids may also be divided into pedunculated and 
sessile, either of which variety may protrude through the anus. 



CAUSES 

A great many different causes have been assigned for hemor- 
rhoids. The principal predisposing cause is the erect position 



188 



DISEASES OF THE RECTUM 



which man assumes, and the lack of valves in the rectal veins, 
causing the weight of the column of blood to rest on the veins 
of the lower rectum and anus. Anything which will abnormally 
increase this weight, or the pressure on the vein wall will, of 




Fig. 126. — Acute thrombotic hemorrhoids of unusual size 




Fig. 127. — External thrombotic hemorrhoids. This specimen, removed from one of the 
author's cases, illustrates the thrombotic nature of the condition. There were four, large, 
distinct thrombi present in this case, and they were removed en masse. 



course, cause dilatation and enlargement. Constipation is an oc- 
casional cause of hemorrhoids. The large, hard stool, as it passes 
down through the rectum, pushing the blood ahead of it, and milk- 
ing the veins, causes unusual pressure in the lower portions of the 
hemorrhoidal plexus at the anal canal. A more common cause, 



HEMORRHOIDS 



189 



however, than constipation is the effort to relieve constipation by 
means of purgatives, the unnatural straining and the irritating 
liquid stools being responsible for more cases of hemorrhoids than 
constipation itself. Overeating and lack of exercise, or anything 
which causes a congestion of the portal circulation, are important 
causative factors in their production. Occupation enters largely 
into their etiology. Men who are on their feet continually — such 
as policemen, letter-carriers, pedestrians, railroad men, traveling 
men — are all peculiarly subject to hemorrhoids. Men are more 




Fig. 128. — External cutaneous hemorrhoids. Drawn from one of the author's cases 
suffering from tertiary syphilis. 



often treated for hemorrhoids than women, not so much because 
they are more subject to hemorrhoids, but because women are 
treated for many gynecological conditions, the relief of which 
relieves the hemorrhoids. Many women who suffer from hemor- 
rhoids caused by the pressure of the pregnant uterus will be spon- 
taneously cured after delivery. 

The most common cause, however, is, in the opinion of the 
writer, the abuse of the cathartic habit. 



190 



DISEASES OF THE RECTUM 



SYMPTOMS 

The three principal symptoms associated with internal hemor- 
rhoids are bleeding, pain, and prolapse. 

Bleeding 1 . — The bleeding is of especial interest. Many patients 
suffering from hemorrhoids scarcely ever, if at all, present the 




Fig. 129. — Granulomata (syphilitic) sometimes erroneously diagnosed as external 

hemorrhoids. 



symptom of hemorrhage. In these cases the mucous membrane 
covering the hemorrhoid is thick and is not easily ruptured, and 
the hemorrhoids may protrude without hemorrhage. Where bleed- 



HEMORRHOIDS 



191 



ing is observed, it may be very slight, consisting of a few drops 
following the stool, or is simply noticed on the toilet paper after 
stool. In other cases it is very profuse, several ounces being 
lost with each stool, and some patients have become profoundly 
anemic from this cause alone. It might be mentioned, in passing, 
that it is extremely important in every case of anemia to inquire 
as to whether the patient is suffering from hemorrhoids or not; 
as not infrequently the rectal hemorrhage will be found to be the 
cause of the trouble, and its relief will be followed by a prompt 




Fig. 130. — Single prolapsing internal hemorrhoid. 



return of the normal amount and quantity of blood. The author has 
observed in anoscopic examination typical arterial spurting from 
the midst of a hemorrhoidal mass. 

Before leaving the subject of bleeding from hemorrhoids, the 
author wishes to utter a word of caution about making a diag- 
nosis of hemorrhoids from the symptom of rectal hemorrhage alone. 
Many a poor unfortunate has gone to an untimely end because 
beginning malignant disease was erroneously diagnosed as hemor- 
rhoids from the symptom of bleeding alone. It makes no dif- 



192 



DISEASES OF THE RECTUM 



ference as to the age of the patient or whether there is pain present 
or absent, the symptom of hemorrhage should never be taken for 
granted as denoting the presence of hemorrhoids, and even where 
hemorrhoids are observed, no one should be satisfied that he has 
made a correct diagnosis until he has made a proctoscopic ex- 
amination (which must include the upper rectum and sigmoid) and 
the presence of commencing malignant disease has been absolutely 
excluded (Frontispiece). 

It is not the intention of the author in this work to cite cases, 




Fig. 131. — Prolapsing internal hemorrhoids at anterior and posterior commissure. 



but he could cite numerous ones seen in consultation where the 
diagnosis of malignant diseases was made too late to save the pa- 
tient's life, because the patient had been allowed to go for months 
— being treated for hemorrhoids without ever having had a rec- 
tal examination made. He had also seen numerous cases of anal 
fissure diagnosed as hemorrhoids simply from the appearance of 
blood following stool. 

Pain. — The pain of internal hemorrhoids is somewhat charac- 
teristic, but not pathognomonic. It is more a dull aching sensa- 



HEMORRHOIDS 



193 



tion accompanied by a feeling of fulness with or without throb- 
bing. It is seldom of an acute nature. The patient complains 
of a constant sense of weight and dragging in the rectum and 
in the sacral region, and is usually more or less mentally de- 
pressed. Many patients having hemorrhoids suffer from no pain 
whatever. 

The pain accompanying the acute thrombotic pile is sudden, 
lancinating in character, and is accompanied by the appearance of 
the tumor. The pain soon becomes of an intense, throbbing charac- 
ter, and the relief given upon the incision of the hemorrhoid and 




U 






« 



-"•% 



j^hawQm? 




-X 



Fig. 132. — Prolapsing' internal hemorrhoids. A suitable case for local anesthesia. 



removal of the clot has to be observed or experienced to be ap- 
preciated. The other varieties of external hemorrhoids are not 
accompanied by pain at all, unless inflamed, but may be accom- 
panied by considerable pruritus. 

Prolapse. — In those cases of internal hemorrhoids which pro- 
lapse (Figs. 130-134), the prolapse is slight at first, gradually 
increasing with time. At first the prolapse is replaced readily 
by the patient after stool, but as time goes on and the prolapse 
becomes aggravated, it will come down not only with the stool 



194 



DISEASES OF THE RECTUM 



but when the patient is up and about and walking. It finally 
remains down and can only be replaced when the patient is lying 
down, or in the knee-shoulder position, and even when held by 
pads or retaining devices soon slips out again, when the patient 
resumes the erect posture and starts to walk. 




F'g. 133. — Prolapsing internal hemorrhoids. This illustrates the extent to which in- 
ternal hemorrhoids may prolapse. This case was of twenty years' standing, and unless the 
hemorrhoids were prolapsed after stool, there was nothing to distinguish the external ap- 
pearance of the anus in this case from the normal. 



DIAGNOSIS 

One would think that much space devoted to the diagnosis of 
hemorrhoids would be superfluous and that the condition almost 
diagnoses itself, but it is because of the many unfortunate er- 
roneous diagnoses of other conditions for hemorrhoids that the 
author wishes to dwell somewhat upon this point. 

In the first place, the average patient, when consulting a phy- 
sician for suspected hemorrhoidal or other rectal troubles, is asked 
to stand in front of a table (Fig. 11) and bend over on it for a 



HEMORRHOIDS 



195 



11 rectal examination," and the physician inserts his index finger 
as far as the patient will allow him, and that is all; or he may 
take a bivalve rectal speculum (Fig. 135), and if he succeeds in 
inserting it far enough, will proceed to dilate. Usually, before 
he has gone very far, the patient is off the table and refuses to 




Fig. 134, — Prolapsing internal hemorrhoids exposed ready for operation. 



allow a repetition of the attempt, and that is about as far as 
the average rectal examination goes. This was even in our recent 
mobilization of an army of over four million men, the type of rectal 
examination given recruits. Thousands of beds in overseas army 
hospitals were occupied by patients whose rectal diseases should 



196 



DISEASES OF THE RECTUM 




Fig. 135. — Bivalve rectal speculum. This is an instru- 
ment formerly used for rectal examinations, but which, in 
the author's opinion, has absolutely no place in modern 
methods of examination. It may be used in operative work, 
and only when the patient is under general anesthesia. 




Fig. 136. — Circumanal injection of anesthetic completed. 



HEMORRHOIDS 



197 



have been discovered at home if proper and modern diagnostic 
methods had been taught at medical training camps, and these 
methods used. 

Now a complete examination (Chapter III) of not only the 
rectum, but the lower sigmoidal cavity as well, may be accom- 
plished, practically without pain, and without any dilating specu- 




Fig. 137. — Showing complete anesthesia and sphincteric relaxation. 

lum. Cylindrical proctoscopes of various lengths are used, and 
through them everything from the anal orifice to the lower sig- 
moidal cavity can be examined ocularly, and an absolutely correct 
view of the actual condition obtained. 

In making an examination for hemorrhoids, first ask the pa- 
tient to lie upon the table in either the right or left Sims' position 
according to the personal preference of the examiner. With the 



198 DISEASES OF THE RECTUM 

finger protected by a thin-rubber finger cot, and properly lubri- 
cated, you proceed as follows: 

After making a careful inspection of the anus and surround- 
ing tissues, press the point of the finger against the anus, asking 
the patient to bear down as if he were trying to force the finger 
out. The palmar surface of the finger should be toward the 
posterior commissure of the anus. Allow the finger to slowly enter 
until you have entered the lower rectal cavity; then, slowly turn- 
ing your finger from side to side, note the conditions. As the 
finger is being withdrawn, it should be swept around slowly, taking 
note of the absence or presence of protrusions or abrasions, depres- 
sions, elevations — in fact, everything which does not feel like the 
normal velvety smoothness of the anal canal. An important thing 
to remember is not to try to feel too high. These conditions will 
all be found within the first two or two and one-half inches, and if 
one does not insert the finger too far, he will be able to detect a 
great many things in this small area. One must remember that 
hemorrhoids of considerable size may not present any unusual feel- 
ing to the examining finger, because of the pressure of the finger 
emptying them of blood, and they are more or less effaced at the 
time. However, one can become sufficiently expert, so that he can 
detect the presence of even these soft elevations, and the sulci be- 
tween them. 

If the hemorrhoids are accompanied by a painful fissure, one 
may not be able to insert the finger without the use of local anes- 
thesia, the te clinic of which will be found in Chapter XV. After 
digital examination has been completed, an anoscope is introduced, 
the obturator withdrawn, and the patient asked to bear down. This 
will prolapse hemorrhoids into the instrument, where they can be 
examined without any difficulty, or have the patient assume the 
squatting position and "strain" the hemorrhoids out. Then intro- 
duce the proctoscope, and following this, the sigmoidoscope. In 
introducing the proctoscope, however, one must employ the knee- 
shoulder position. It is in this position only that satisfactory dila- 
tation of the rectal cavity by pressure of the atmospheric air can 
be obtained. The folds and creases are all smoothed out, and every 
portion of the rectal lining mucous membrane can be explored with 
the eye ; the size and condition of the rectal valves can be deter- 
mined, and the presence or absence of ulcers of the rectal wall as 



HEMORRHOIDS 



199 



well. The sigmoidoscope is entered in this position, the exagger- 
ated lithotomy or inverted position, and having an obturator the end 
of which can be turned at an angle, it can round- the rectosigmoidal 
curve without difficulty. Even the pneumatic sigmoidoscope is 
used with better success in this position, because the pelvic organs 
all fall away from the bowel and allow freer dilatation. 

Thus it will be seen that this entire region can be successfully and 
completely examined without using an instrument which will dilate 
the sphincter any more than the base of one 's index finger. No dila- 
tation is required, and no pain is experienced by the patient. Of 
course, during the examination it may be required to swab out or 




Fig. 138. — A single interno-external hemorrhoid injected with anesthetic solution ready 

to operate. 

irrigate the rectum, all of which can be readily done through the 
instruments mentioned. 

Differential. — In the differential diagnosis between hemorrhoids 
and other conditions, which may simulate some of their symptoms, 
one might mention first, fissure. 

Fissure. — Fissure of the anus, which may accompany hemor- 
rhoids, is more often found alone. The pain of fissure is almost 
diagnostic; it is sharp, cutting, most intense during the passage 
of a stool. It remains often for several hours following stool, and 
is accompanied by more or less tenesmus and spasm of the sphincter 
muscle. The bleeding of fissure always accompanies or follows the 
stool. It may consist merely of a blood streak on the stool or sev- 



200 DISEASES OF THE RECTUM 

eral drons of blood following the stool, or it may merely be a spot 
or smear on the toilet paper. The presence of a fissure causes the 
patient to put off the bowel movement as long as possible, and when 
he does defecate, the hard fecal masses cause more pain and discom- 
fort than before. Digital examination reveals a fissure with more 
or less indurated surrounding tissue, situated most often at the 
posterior commissure, or in either the right or left latero-posterior 
quadrants. 

Ulcer. — Ulcer of the rectum may be incorrectly diagnosed as 
hemorrhoids, on account of more or less slight hemorrhage which 




Fig. 139. — Injection of anesthetic solution into a prolapsing hemorrhoid, showing the 
amount of distention necessary for anesthesia. 

may accompany it. Ulcer, however, is usually accompanied by 
diarrhea, and ocular examination, after eliciting a history of blood 
in the stool, will settle the diagnosis at once. The same may be 
said of proctitis. An intensely congested and injected rectal mu- 
cous membrane may bleed on stool; but if the conscientious prac- 
titioner examines every patient who presents the symptom of blood 
in the stool, many sources of hemorrhage other than hemorrhoids 
will be detected, and the correct diagnosis made. 

Cancer. — Of course, the one important thing always to bear in 
mind when the symptom of hemorrhage is present is the possibility 



HEMORRHOIDS 



201 



of the presence of cancer. Cancer, well advanced, may be found in 
patients who present the appearance of perfect health. When a 
patient of any age, from childhood up (just as often below forty as 
above), presents a history of rectal hemorrhage, which has been 
preceded by more or less digestive disturbance, including diarrhea 
alternating with constipation of several weeks' or months' stand- 
ing, with considerable intestinal gas — even though there is no evi- 
dence of cachexia or loss of weight — one should be extremely sus- 
picious of malignancy somewhere in the intestinal tract. If the 
blood is of a dark color either of a tarry nature or genuine coffee- 




Fig. 140. — A prolapsing' interno-external hemorrhoid at anterior commissure, anesthetized 

ready to operate. 

ground, the location of the cancer is higher up. If the blood is 
fresh, bright red in color, and closely follows the stool, and has a 
more or less nauseating odor accompanying it (an odor which is 
almost pathognomonic), one should examine very carefully for com- 
mencing cancer in the rectum or sigmoid. When one considers that 
fifty per cent of all cancers occur in the gastrointestinal tract, and 
when one realizes that sixteen per cent of all cancers of the diges- 
tive tract occur in the rectum or sigmoid, one can readily under- 
stand how important it is to examine every case which presents the 
symptoms of rectal hemorrhage. 



202 



DISEASES OF THE RECTUM 



Protrusions. — Various protrusions may be mistakenly diagnosed 
as hemorrhoids. Polypi, which may occur at any age, but occur 
more often in children, protrude with the stool. They are harder, 
more fibrous in character than hemorrhoids, and when replaced by 
the finger, go back into the rectum with more or less of a snap, 
which is somewhat characteristic of this condition. Anoscopic ex- 
amination shows the polypus to be a small, rounded, hard, fibrous 




Fig. 141. — Distention completed, showing internal hemorrhoids presenting. 

tumor, attached by a pedicle narrower than itself, its usual attach- 
ment being somewhat higher in the lower rectal cavity than that 
of a hemorrhoid. Enlarged anal papillae have been diagnosed as 
connective-tissue piles. The enlarged papilla, however, is small, 
always triangular, though occasionally long drawn out and some- 
what ribbon-shaped. It is pinkish in color and does not contain 



HEMORRHOIDS 



203 



varicose veins. The point or tip is always downward, and it is at- 
tached by its base or widest portion. They are situated at the junc- 
ture of the anus and rectum, at the lower edges of the crypts of 
Morgagni. 

Venereal warts of large size have been incorrectly diagnosed as 
external integumentary piles (Fig. 129), but close inspection, after 
obtaining a history of discharge from venereal disease, should make 
the diagnosis evident. Occasionally the protrusion of an anal or 
perianal abscess may simulate an inflamed external hemorrhoid. 
However, with the finger of one hand in the rectum and the other 




Fig. 142. — Method of injecting prolapsing pedunculated internal hemorrhoids. 

hand on the protrusion, the site of the abscess cavity can be made 
out, and fluctuation often determined. The sudden onset, accom- 
panied by the intense pain, swelling, redness, and rise of temper- 
ature, always points to abscess formation rather than to hemor- 
rhoids. 

The protrusion which is often mistaken for prolapsed hemor- 
rhoids is prolapsus ani or recti. There are three degrees of pro- 
lapsus: 



204 



DISEASES OF THE RECTUM 



1. Simple eversion of the anal mucous membrane. 

2. The descent outside of the rectum of more or less of all coats 
of the rectum. 

3. The descent of the entire rectum with more or less of the sig- 
moid, which may come down to the anal orifice but not necessarily 
protrude. 




Fig. 143. — Perfect exposure of operative field by use of Pennington forceps. 

Prolapsed mucous membrane is differentiated from prolapsed 
hemorrhoids by its smooth, velvety touch, reddish color, and the 
absence of varicose veins. It is continuous with the rectal mucous 
membrane, and a distinct sulcus can be made out between the anus 
and the protrusion in the second and third varieties. In the first 
variety, careful examination will show it to be mucous membrane 



HEMORRHOIDS 



205 



continuous with anal skin. Of course, in aggravated cases of pro- 
lapsed hemorrhoids more or less prolapse of the mucous membrane 
of the anus will accompany it, and the diagnosis is self-evident. 

TREATMENT 

The treatment of hemorrhoids we shall divide into palliative and 
radical. 




Fig. 144. — Grasping hemorrhoid with author's hemorrhoid forceps. 

Palliative. — The palliative treatment of hemorrhoids is, however, 
not a cure, but a relief of acute symptoms for a more or less short 
period of time. When the patient presents himself suffering from 
acute prolapsed internal hemorrhoids with more or less strangula- 
tions by a contracted sphincter, the first thing to do is to reduce the 



206 



DISEASES OF THE RECTUM 



prolapse. This is not always so easy as it seems. The contraction 
of a sphincter on the hemorrhoids shuts off the return blood supply, 
and the hemorrhoids swell so much that they cannot be replaced 
without anesthesia. If however, a solution of adrenalin chlorid 
(1:1000) or glycerin be applied by means of compresses, the blood- 
vessels will shrink to such an extent that reduction is often possible. 
Sometimes the application of cold or alum solutions will cause 
sufficient shrinkage to make reduction easy. Chloretone, % P er 
cent, apothesin 1 per cent, or eucain 1 to 4 per cent may be added 
to these solutions to render them analgesic. Occasionally, applica- 
tions of nuidextract of ergot will help in maintaining the contrac- 
tion of the vessels after adrenalin has brought them down. An 
ointment containing adrenalin, 1 :1000, chloretone, 20 grains to the 
ounce in lanolin, injected into the anus after stool and three or four 
times a day, at regular intervals through a long-nozzled collapsible 




Fig. 145. — Author's hemorrhoidal forceps. 

tube, will often assist in allaying an acute attack of hemorrhoids. 
However, all of these treatments are merely palliative, and the 
hemorrhoid upon the slighest irritation will enlarge, prolapse, and 
even strangulate again. 

Some patients who absolutely refuse more radical measures will 
submit to cauterization of the hemorrhoid by the thermocautery, 
thus causing a deposition of scar tissue on the surface of the hemor- 
rhoid, which by its contraction somewhat lessens its size, and re- 
peated applications of the cautery will reduce the hemorrhoid so 
that it will not be noticeable for some time. Occasionally such ir- 
ritants as glacial acetic acid, chromic acid, and saturated solution 
of nitrate of silver have been used for a like purpose. The puncture 
of the hemorrhoidal mass in various places by means of the electric 
needle, as advocated by Kelsey, has been of some assistance in re- 
ducing the size of internal hemorrhoids, but never entirely removes 
them. 



HEMORRHOIDS 



207 



Injection Treatment. — The "injection treatment," which is the 
treatment usually advocated by most of the irregulars, may be ap- 
plied in a number of ways. The patient's rectum is cleansed by 
means of a simple enema, followed by one of saturated solution 
of boric acid or some other antiseptic. The hemorrhoid, which 
should be of the prolapsing variety and one that can be easily ex- 




Fig. 146. — Passing submucous ligature. 

traded into the anoscope, or outside, is injected down to its base 
with either a mild solution containing carbolic acid up to 5 or 10 
per cent, when one wishes to cause a mild inflammation and gradual 
occlusion of the blood-vessels by the deposition of fibrous tissue, or 
a strong solution of carbolic acid running from 20 per cent to 50 



208 



DISEASES OF THE RECTUM 



per cent, when one wishes an immediate slough of the hemorrhoidal 
mass. 

When one has but one or two, or not to exceed four, prolapsing 
hemorrhoids, this method may be applicable, each hemorrhoid be- 
ing injected at the time. In some cases two or three injections are 




Fig. 147. — Eigature tied with a long and a short end. 



necessary for each hemorrhoid at intervals of five or six days, but on 
account of the danger of injecting a blood-vessel, and on account of 
the inability to limit the slough caused by carbolic acid, it is rather 
an unsafe method; and repeated instances of destruction of large 
areas of tissue, and sepsis, have been reported. 



HEMORRHOIDS 



209 



A rather ingenious method of applying the injection treatment 
has been advocated by Franck, of Berlin. He employs a 50 per 
cent solution of carbolic acid in alcohol, and uses it as follows: The 
hemorrhoid is rendered tense by the application of a wire snare 
around its base ; this is gradually tightened so as to cause the tumor 




Fig. 14S. — -Rectal retractor modified from Sims' specuh 




Fig. 149. — Author's blunt-pointed ligature carrier. 



to be slowly congested; the needle is then planted in the center of 
the mass, and several drops of the solution slowly injected. The 
snare is not removed until the whole mass has undergone throm- 
bosis. Each time it is treated in a like manner, and a dressing of 
some drying powder is applied. In seven or eight days the necrotic 



210 



DISEASES OF THE RECTUM 



tissue will slough off, and the granulating surface will be healed in 
three or four days. This long period of granulation is another ob- 
jection to the application of the injection method. 

The best and safest of the injection treatments is the use of 5-10 
per cent solutions of quinin-urea hydrochloricl as advocated by 




Fig. 150. — All ligatures tied in situ. 



E. H. Terrell of Richmond, Va. From 5 to 20 drops of the solution 
are injected well into the center of each hemorrhoid, not more than 
one or two at a sitting. The patient returns daily until all are in- 
jected. The hemorrhoids gradually shrink, until at the end of two 
or three weeks they have almost disappeared. 



HEMORRHOIDS 



211 



The contraindication to the use of the strong quinin-urea solu- 
tions in anesthesia — the interference with circulation — is here em- 
ployed as a curative agent. 

"With the introduction of local anesthesia in the radical treatment 
of anorectal diseases, the field for the injection method has been 
greatly encroached upon. It seems to the author much more ra- 
tional to remove the hemorrhoid by a clean-cut surgical incision, 
under local anesthesia, and have the patient up and about on the 
second day, and the wound healed in from a week to ten days (this 




Fig. 151. — Internal hemorrhoid anesthetized, ready to remove 
hemorrhoidal forceps. 



rasp of author's 



under local anesthesia in office practice) than to use the uncertain, 
unscientific injection methods. Therefore, the author will confine 
himself in this chapter to a description of the various methods of 
operating on hemorrhoids under local anesthesia, as applicable in 
office practice. 

Operative Treatment Under Local Anesthesia. — The technic of 
producing local anesthesia is, briefly, as follows (Chapter XV) : 

The patient, who has previously had a boric-acid enema, is placed 
on the table in the Sims position. A large glass hypodermic syringe 



212 



DISEASES OF THE RECTUM 



is filled with the solution of choice, which may be apothesin, pro- 
cain, quinin and urea hydrochlorid, cocain, eucain, alypin, novocain, 
chloretone, or simple sterilized water, as the case may be demand. 
Aposthesin % per cent or beta-eucain lactate, any strength varying 
from y 2 to y 10 per cent, is used for anesthetizing the sphincter and 
is injected in the following manner: 




Fig. 152. — Excision of hemorrhoidal tissues, conserving mucosa. 



After sterilizing the parts, a point one-half inch below and pos- 
terior to the posterior commissure of the anus is selected. The ap- 
plication of a swab dipped in pure carbolic acid is used to deaden 
the pain which accompanies the introduction of the needle (Fig. 



HEMORRHOIDS 



213 



82). With one index finger in the anus, hooking clown the sphincter 
the needle in the other hand is passed inward, upward, and later- 
ally, in a V-shaped direction for about three fourths of an inch, go- 
ing down into the sphincter muscle, but not through it. From ten 
drops to a dram of the solution is slowly injected, and the needle 
is retracted to the point of puncture, but not withdrawn; then it is 
pushed up on the other side in the same manner, keeping about one- 
half inch away from the anal aperture (Fig. 190). 

Then at least five minutes are allowed to pass to give the anes- 




Fig. 153. — The blood supply of all hemorrhoids controlled by four ligatures. 



thetic time to take effect. The sphincters will then be found suf- 
ficiently relaxed and dilated for any ordinary rectal operation (Fig. 
137). 

When the sphincter is dilated, the hemorrhoid is injected from its 
base to its apex, with % P er cen t solution of quinin and urea hydro- 
chloric!. The particular point to remember is that distention must 
be carried until the tissues are blanched and the hemorrhoid is in 
appearance not unlike a Malaga grape (Figs. 138, 139, 140, 141). 



214 



DISEASES OF THE RECTUM 



It is very seldom necessary to ligate any vessels, as their retrac- 
tion very soon causes the hemorrhage to cease. 

The operation is then proceeded with according to the technic 
outlined below. 

A suppository, containing three grains of thymol iodid, two 
grains of chloretone, and five grains of quinin and urea hydro- 
chlorid, may be inserted if desired, and a dressing applied, but the 




Fig. 154. — Long end of ligature tied in needle. 

patient is not allowed to get up from the table for about ten min- 
utes, then is asked to rise slowly and either sit down or lie down 
as he wishes. I have found that, when a patient is allowed to get up 
immediately, some dizziness or faintness is complained of, and I 
formerly attributed it to the chemical anesthetics injected, until I 
found that it also occurred in those patients in whom sterile water 
alone was used as an anesthetic. 



HEMORRHOIDS 



215 



Excision. — The hemorrhoid having a pedicle is injected at its base 
(Fig. 142) with % per cent solution quinin and urea hydrochlorid — 
the distention carried to blanching of, the tissues, the base trans- 
fixed with a double-threaded needle (chromic catgut being used), 
and the ligature double tied. The hemorrhoid is then cut off, leav- 
ing sufficient stump to prevent slipping of the ligature. Each one 
is treated in like manner, a suppository of the composition men- 




155. — All hemorrhoids ligated and ligatures ready to be vised as sutures. 



tioned above inserted, the bowels kept from moving for two or three 
days, and the patient allowed to be up and around after the first 
twenty-four hours. The patient is sent home usually in a taxicab 
(occasionally they will walk or take the car), and is advised to lie 
on either one side or the other for twenty-four hours and then re- 
sume his occupation. It is surprising with how little discomfort 
they are able to get around and how quickly they recover. 



216 



DISEASES OF THE RECTUM 



The hemorrhoid, which is sessile or non-pedunculated, is dis- 
tended in the same manner as above. The most dependent portion 
is grasped with the author's pile forceps (Fig. 144) or toothed for- 
ceps; it is dissected up from its base with either knife or scissors to 
healthy tissue, care being taken to include in the dissection the ves- 
sels which enter the hemorrhoid from above. The upper part of the 
flap is transfixed and tied off, as is the pedicle in the above variety, 
when the tumor is cut off with the scissors ; others treated in like 
manner, and the after-treatment is the same as above. It is a very 




Fig. 156. — Eong ends of ligatures tied to their respective short ends, drawing wound edges 

together. 



rare thing for the author to have hemorrhage severe enough to re- 
quire ligation of the vessels. Where there is more or less oozing, a 
piece of rubber-tubing, about four inches long and surrounded by 
gauze, is inserted, and the pressure of the gauze against the raw 
surface very soon checks oozing. This is removed in anywhere 
from one to twenty-four hours. 

Author's Bloodless Operation. — A somewhat simple method is 
the author's technic for the removal of most all forms of internal 
hemorrhoids without the profuse hemorrhage with which this oper- 



HEMORRHOIDS 



217 



ation is usually associated in the minds of most medical practition- 
ers. From the observation that most patients suffering from hemor- 
rhoids of the internal variety are more or less anemic from the 
continued and constant loss of blood, as a result of their hemor- 
rhoidal trouble, he decided to use a technic that would minimize oper- 
ative hemorrhage and conserve the patient's blood supply. With 




Fig. 157. — Edges in position for suturing. 



this aim in view, he has developed and has been using a very simple 
technic which is presented below: 

It is applicable under local as well as general anesthesia, and 
therefore can be used in those weak, run-down patients suffering 
from any of the wasting diseases, in whom the use of a general anes- 
thetic would be inadvisable, if not positively dangerous. The method 



218 



DISEASES OF THE RECTUM 



is applicable to any variety of internal hemorrhoids, and particularly 
to the pedunculated and prolapsing varieties. Interno-external 
hemorrhoids can also be treated by this method. Very few instru- 
ments are required, and in most cases dilatation of the sphincters is 
not required. The technic under general anesthesia is much the 
same as under local anesthesia, and inasmuch as local anesthesia is 




Fig. 158. -^Technic of suturing. 

a good deal safer and fully as satisfactory as general anesthesia for 
this work, the author will describe the operation as performed by 
him under local anesthesia. 

The instruments required are four to six Pennington triangular 
forceps or a rectal retractor (Fig. 109) or Sims' speculum; the 



HEMORRHOIDS 



219 



author's blunt-pointed ligature carrier, the author's pile forceps, 
scalpel, sharp-pointed scissors curved on the flat, aseptic hypoder- 
mic syringe with sharp needle, and chromic catgut. The patient is 
given one-fourth grain of morphin and %5o grain of hyoscin about 
a half -hour before the operation is performed; the bowels are washed 
out with a soap-suds enema, followed by a boracic acid enema. He 




Fig. 159. — Completing the suturing. 



is then placed on the operating-table in the Sims lateral position; 
the skin around the anus is scrubbed, shaved, and sterilized. The 
sphincters are then anesthetized by the injection of 20 to 30 minims 
of Y 2 per cent solution of apothesin or % per cent beta-eucain lac- 
tate solution, which has been sterilized by boiling, according to the 
technic described above. 



220 DISEASES OF THE RECTUM 

The skin surrounding the entire anal circumference is injected 
as well, so as to allow the grasping at four equidistant points with 
the Pennington triangular forceps. This gives us, on gentle trac- 
tion, the best exposure of the operative field, that it is possible to 
procure (Figs. 143 et seq.). 

When relaxation and exposure have been accomplished, the most 
dependent hemorrhoid is injected with % per cent solution of quinin 
and urea hydrochlorid, and the distention carried until the tissues 
are blanched. Anesthesia is then complete. The lower extremity 
of the hemorrhoid is then grasped with the author's pile forceps 
(Figs. 144, 145) and pulled down so that it is on the stretch. The 
blunt-pointed ligature carrier, threaded with No. 2 catgut, is passed 
in through the mucous membrane on one side, down to the base of 
the hemorrhoid and around to the opposite side, in such a manner 
as to include the upper half of the mucous membrane covering the 
pile, and the blood-vessels underneath, but not encircling the entire 
hemorrhoid as in ligating a pedicle (Fig. 146). This ligature should 
be placed just at or above the juncture of the pile and the healthy 
mucous membrane of the rectum. It is then firmly tied (Fig. 147), 
and it will be found that the blood supply of the pile has been in- 
cluded in the ligature and shut off (Fig. 150). The piles at either 
side are treated in like manner and lastly the upper ones. A sup- 
pository containing: 

Chloretone gr. ij 

Tliymolis iodidi gr. ij 

Quininae hydrochloridi carbamidati gr. x 

is inserted, the patient keeping in the recumbent position for ten 
minutes, and then allowed to rise from the table and go to his bed. 
If there should be considerable swelling during the first twenty- 
four hours, this, with its accompanying pain, can be relieved 
by the application of hourly compresses soaked in the following 
solution: 

It Adrenalin chlorid (1 : 1000) gss 

Chloretone gr. xxx 

Glycerini giv 

The swelling subsides in from two to four days, and the pile grad- 
ually shrinks until at the end of four weeks there is nothing left 
but a little hard "nub" of connective tissue, which can then be re- 



HEMORRHOIDS 



221 



moved painlessly with the scissors. This, which is the simplest form 
of technic, is applicable in those desperate cases of anemia where 
the continual loss of blood from the hemorrhoids is greater than the 
patient's blood production. It can be done in ten or fifteen minutes 
and involves the least expenditure of nerve endurance and suf- 
fering of the patient. In cases where the necessity for haste is not 
quite so imperative, and these cases are the great majority, I use 
the following modification of the technic : 




Fig. 160. — Skin closure. 



After the hemorrhoid is anesthetized as above, and the ligature 
applied in the same manner, the pile is grasped in the author's pile 
forceps, and an incision made in its longitudinal axis, and extending 
down to its distal extremity; then, with the curved scissors, the 
blood-vessels and connective tissue which make up the body of the 
pile are dissected out en masse (Fig 152) and cut off about one 
quarter of an inch from the ligature. The wound is left open to 



222 



DISEASES OF THE RECTUM 



heal by granulation, which it does in a very few days. This dis- 
penses with the hemorrhoid at once and does away with the swell- 
ing, pain, and discomfort which necessarily follow the preceding 
te clinic. 

In cases where we have pedunculated, prolapsing hemorrhoids, it 
is not necessary to dilate the sphincter or use the retractor. Fol- 
lowing an enema, the patient is asked to strain while in the squat- 
ting position or lying on his side, while the operator is everting 




Fig. 161. — Operation completed. 



and pressing back the sphincter muscles by pressure just outside 
the outer margins of the external sphincters. The pile which is 
prolapsed by this method is injected with 1 per cent solution of 
quinin and urea hydrochlorid. Its pedicle is transfixed with the 
blunt ligature carrier double threaded with catgut, and tied off in 
two sections. The pile is then cut away one quarter of an inch 
from the ligature, and the stump cauterized with 95 per cent car- 
bolic acid. The other pedunculated hemorrhoids are treated in 



HEMORRHOIDS 



223 



like manner, the analgesic suppository inserted, and the operation 
is completed. 

Modifications of this technic include the substitution of the rectal 
retractor (Figs. 148, 151) for the triangular forceps in the expos- 
ure of the hemorrhoids ; also the using of the long end of the liga- 
ture as a suture for closure of the incisions (Figs. 147, 150, 152, 
154-161). This is sometimes done for hemostatic reasons in hemo- 
philics, or others where there is more than the usual amount of ooz- 
ing. 




Fij 



162. — Distention of external hemorrhoids with sterile water. This photograph is taken 
from the same case as Fig. 67, and comparison of the two will be of interest. 



The after-care is very simple, the bowels being confined for two 
or three days. A dram of compound licorice powder at night, fol- 
lowed by a six to ten ounce soap suds or oil enema in the morning, 
will produce an easy and satisfactory movement at the end of that 
time. A tablespoonful of liquid petrolatum, daily before retiring, will 
keep the bowels in good order, and daily soft movements will fol- 
low. The only dressing required is a powder, such as compound 
stearate of zinc, which should be applied sufficiently often to keep 
the parts protected. Some of the many advantages of this method 
are as follows: 



224 DISEASES OF THE RECTUM 

1. The teclmic is simplicity itself. 

2. It is applicable under local anesthesia. 

3. It takes a shorter time than any other method which suc- 
cessfully disposes of the hemorrhoid. 

4. It is surer, safer, and quicker than the "injection method," 
and is applicable in every case where the injection method can 
be used, as well' as in other varieties of hemorrhoids where the 
injection is contraindicated. 

5. It should be the method of choice in all patients suffering 
from anemia, tuberculosis, hemophilia, and in pregnancy — because 
of all the foregoing reasons, and the fact that it does not involve 
the loss of blood. The principle of tying before cutting reduces 
the waste of blood to a minimum, and makes for rapid convales- 
cence. 

6. There being no confinement in bed after the first twenty-four 
hours, the patient may be up and about, going out of doors, get- 
ting fresh air, sunlight, and exercise, which are nature's best cura- 
tive agents in convalescence after any operation or disease, and of 
the greatest value to patients suffering from any of the wasting 
diseases mentioned above. 

Submucous Excision. — In the sessile variety, another way of 
treating these is simply to make an incision in the longitudinal 
axis of the bowel through the center of the mass, and then by the 
use of the author's angular rectal scissors (Fig. 62) to macerate 
and destroy the blood-vessels, beneath the mucous membrane on 
either side of the incision. The blood supply being destroyed 
and the macerated tissue cleaned out with a curette, the wound 
is allowed to heal without suture, and usually does in four or five 
days. Of course, this method is accomplished by some, hemor- 
rhage, but never severe enough, however, to require ligature. 
The after-treatment is the same as in the other varieties. 

Clamp and Cautery Operation. — The clamp and cautery opera- 
tion is not applicable, of course, under local anesthesia, and I 
mention it merely to condemn it. I do not believe that the use 
of a red-hot iron in a cavity lined with mucous membrane is 
rational, and while I am aware that many surgeons have used it 
with many successful results, I have seen strictures following its 
use which were caused by the overgrowth of scar tissue — which 



HEMORRHOIDS 225 

is more prone to follow a burn than any other form of wound. 
A clean-cut surgical incision, to my mind, is more rational and is 
not followed by the extensive sloughing; or the extensive cicatrix. 
Crushing the hemorrhoid with the angiotribe has also been used 
by some operators, and offers the objection that it destroys too 
much mucous membrane and is followed by a more or less chronic 
granulating surface taking weeks to heal. 

Whitehead Operation. — The Whitehead operation is, in the au- 
thor's opinion very seldom, if ever, indicated. 

Other Methods. — Other methods of disposing of large redundant 
hemorrhoidal masses by means of elliptical flaps, longitudinal in- 
cisions, and plastic work are used to obviate the necessity of doing 
any operation, which is almost certain to be followed by sepsis, 
retraction of flaps, and subsequent cicatricial contraction. The 
author has yet to see a case of hemorrhoids accompanied by pro- 
lapse so severe that he has not been able to remedy it without 
sacrificing the normal contour of the anus. 

Removal of Acute Thrombotic Hemorrhoids. — The acute throm- 
botic variety (Fig. 124) is peculiarly amenable to treatment under 
local anesthesia. On account of its sudden onset and the acute 
suffering which it produces, the patient will present himself for 
treatment within a few hours after its onset. Examination in the 
lateral position shows a rounded, bluish or purple tumor, varying 
in size from that of a pea to a large grape, located just at the 
anal margin, usually on one side. It usually occurs singly. After 
the usual preparation, the hemorrhoid is injected from its outer- 
most aspect with 10 or 12 drops of % per cent solution of apothesin 
or eucain lactate — the injection being carried just underneath the 
skin or mucous membrane, and not down into the pile. After 
allowing five minutes for the anesthetic to take effect, an incision is 
made through the skin and down to the clot, parallel to the long- 
axis of the anus and extending for about one quarter of an inch 
into the skin beyond the tumor. The tissues around the tumor 
and below it are again injected, when it is dissected out by means 
of a small-toothed forceps and the curved scissors. After the 
clot (Fig. 127) is removed, look carefully into the wound to see 
whether a second clot has formed below, and if so, it must be 
removed at the same time. The edges of the wound are trimmed 



226 DISEASES OF THE RECTUM 

back in an elliptical manner, so as to leave a gaping wound, which 
will heal by granulation from the bottom, without any possibility 
of the edges of the wound turning in and retarding its healing. 
A one-half -inch strip of tape or gauze may be lightly inserted into 
the wound, and a sterile dressing applied. This gauze is removed 
in twenty-four hours, when it will not be found necessary, as a 
general rule, to re-dress the wound. It should be seen and dressed 
daily, and some mild antiseptic powder may be applied, such as 
thymol iodid, boric acid, boro-chloretone, stearate of zinc, or 
acetanilid. The patient, immediately after this operation, experi- 
ences a keen sense of relief from the removal of the tension caused 
by the thrombotic mass. 

Removal of External Integumentary Hemorrhoids. — The re- 
moval of external hemorrhoids of the integumentary (Fig. 67) 
variety is very easily accomplished under local anesthesia. After 
the parts are cleansed, shaved, and sterilized, with the patient 
placed in the left lateral or lithotomy position, the most dependent 
pile is selected, the point of puncture touched with a drop of pure 
carbolic acid or sprayed with ethyl chlorid until the tissues are 
blanched, when the spray is removed, and as soon as it has re- 
gained its natural color the injection is made. As in all operations 
involving the skin, the first injection should be of Y 2 per cent 
solution of apothesin or eucain lactate, care being taken to inject 
the first t-en or fifteen drops just underneath the skin along the 
line of the proposed incision so as to form a wheal or welt. 
An incision is then made on a line radiating at right angles from 
the anal orifice to the distal extremity of the tumor; then the sub- 
cutaneous tissues are infiltrated with % per cent solution of the 
anesthetic used or sterile water. The hemorrhoidal mass is then 
seized with the author's hemorrhoidal forceps and removed with 
flat curved scissors. The skin edges are trimmed back on either 
side in the shape of an ellipse, so as to include all of the redundant 
tissue which forms the covering of the pile. One must be cautious 
about cutting away too much skin. The distention with the anes- 
thetic solution someAvhat distorts and distends the skin, and the 
infiltration extends beyond the part to be removed, making it ap- 
pear much larger and extensive than it is in reality (Fig. 162). 
It is a wise plan, therefore, to carefully mark out, before pro- 



HEMORRHOIDS 227 

ceeding to operate, the extent of the proposed incision by means 
of a small swab moistened with silver nitrate. Each hemorrhoid is 
treated in like manner, working from below upward, and the wound 
is alloAved to heal by granulation. There is no objection to put- 
ting a couple or silkworm stitches in each wound, if desired; but 
the author has found healing fully as satisfactory without stitching, 
and the time of operation is materially lessened, which is an im- 
portant factor in all work under local anesthesia. 

The after-care is similar to that outlined in the treatment of 
acute thrombotic hemorrhoids. The healing following the operation 
for external hemorrhoids should be complete in a week or ten days. 

During the healing process, the patient should be required to 
use an inflated air cushion, or pillow, when sitting, and to lie 
upon either side rather than upon the back. As has been stated 
above in the treatment of internal hemorrhoids, it is wise to put 
the patient upon a light diet, consisting of meat-broths, and strained 
vegetable soups, with the addition of eggs and gelatins, for the first 
three or four days. The bowels should be confined until the third 
day, when by means of a dram or two of licorice powder given 
the night before, followed in the morning by a suds or ten-ounce 
oil enema, the bowels should be moved. • The movements thereafter 
should be kept soft by the administration of half-ounce doses of 
white refined petroleum oil daily at bedtime, and the diet gradually 
increased. After the first movement, daily evacuation of the bowels 
should be secured. 

Eemoval of Interno-external Hemorrhoids. — The same technic 
as outlined for the removal of internal hemorrhoids above is to 
be followed in the case of the combined varieties. The infiltra- 
tion is carried out so as to include the external tumors, and the 
incisions extended likewise. The after-care is also identical. 



CHAPTER XI 

RECTAL POLYPI— HYPERTROPHIED ANAL 
PAPILLA— CRYPTITIS 

POLYPUS 

A polypus is a non-malignant tumor, whose chief characteristic 
is its attachment to the rectal Avail by a pedicle, which is always 
narrower than the tumor (Figs. 163, 164). It occurs more often in 
children than in adults. Polypi may be found singly or in such 
large numbers as to entirely fill the rectal cavity or whole colon 
(Figs. 165, 166) and will be found complicating anal fissure, hemor- 
rhoids, prolapse, and other rectal diseases. 

The usual location of a single polypus is in the lower end of the 
rectal canal from one to two inches from the anal opening. Rarely 
cases have been seen in which the polypus was found attached by 
a pedicle four or five inches long as high as the rectosigmoidal 
juncture. 

The types of polypi most commonly seen are either the soft 
myxomatous or adenomatous variety, or the hard fibroid poly- 
pus. In appearance, the soft granular polypus resembles a rasp- 
berry, and bleeds readily at the touch. The fibroid variety is 
hard, rounded, and lighter in color than the normal rectal mucous 
membrane. 

Symptoms. — The usual symptoms, outside of the appearance of 
the polypus itself, are the passage of blood and mucus, and strain- 
ing efforts after stool — the patient complaining of a feeling as if 
more fecal matter were in the rectum, but it was impossible to 
evacuate it. 

Diagnosis. — The diagnosis is very simple, as they are often dis- 
covered protruding from the anus. A peculiar characteristic of 
polypi is the snapping sensation which they give to the finger as 
they are returned to the rectum. On making a digital examina- 
tion, with the patient in the lateral position, one should insert 
the finger as high as possible, and then sweep it from side to side, 

228 



RECTAL POLYPI ANAL PAPILLiE CRYPTITIS 



229 



completely encircling the rectum on its withdrawal, when the polypi 
will be discovered, usually just above the internal sphincter. As 
the finger is withdrawn, the polypi can often be brought with 
it, outside the sphincter. By means of proctoscopic examination, 
polypi situated higher in the rectum may be discovered. 




Fig. 163. — Anal polypus. 



Treatment. — In the treatment of polypi, local anesthesia is often 
not necessary. They can be snared off with ease through the 
anoscope or proctoscope with little or no pain. Where a polypus 
is situated low, so that it can be extruded through the anus, the 
pedicle may be infiltrated with % P er cent solution of apothesin 
or eucain, or % per cent quinin and urea hydrochlorid, transfixed 



230 



DISEASES OF THE RECTUM 



with a double-threaded needle, and the pedicle tied off in two sec- 
tions with a double ligature. The polypus is then snipped off 
with scissors, leaving as little stump as is possible. It is prac- 
tically never necessary to anesthetize the sphincter, and no after- 
treatment is required. 



HYPERTROPHY OF THE ANAL PAPILLAE 

In devoting some space to the anal papillae, the author has done 
so with the view of bringing before the profession a condition 




Fig. 164. — Rectal polypus. 

which is practically never recognized by the general practitioner, 
and usually overlooked by the general surgeon, who includes rec- 
tal surgery as an incident in his practice. It is one of the many 
minor conditions which originate in the anal canal, which, while 
never causing such serious symptoms as to endanger health or 
life, or causing such great suffering as to incapacitate the patient 



RECTAL POLYPI ANAL PAPILLiE CRYPTITIS 231 

from his daily occupation, nevertheless, is of no small interest 
to the medical practitioner because of the amount of discomfort 
it causes. 

This may amount only to a feeling of uneasiness, but the hy- 
pertrophied anal papilla is often responsible for symptoms ridicu- 
lously out of proportion to the size and severity of the lesion. 

Many irregular practitioners, who hold themselves out as "rectal 
specialists," have made great capital out of the anal papillae and 
have attributed to them the causation of nearly every disease in 
the calendar. As a result, many of the profession have gone to the 
other extreme, and have completely ignored the existence of what 
has been proved to be definite diseased conditions of definite 
anatomical entities. 

When a patient complaining of indefinite rectal or anal symp- 
toms consults his physician, too often he is dismissed with some 
proprietary ointment, without any effort being made to locate the 
cause of the trouble. The special study of the rectum, with its 
allied organs, the anus and the sigmoid, has brought to view many 
interesting conditions which have been overlooked in the past, and 
it is with the view of clearing up some of the obscure and in- 
definable symptoms which originate in the region of the anus, that 
the author is devoting this space to hypertrophy of the anal papillae. 

It is in the anal canal, where most of the pathological conditions 
which cause pain and suffering, and reflexes without number, orig- 
inate. Nature has been unusually lavish in her sensory nerve 
supply to these organs, and lesions in this region produce referred 
disturbances in many other and remote organs. When one con- 
siders that the anal canal measures from two-thirds to an inch 
and a quarter in length and its circumference about one and one- 
quarter inches in the contracted condition, one can readily see 
that it is not a large area to examine and study, and diseased con- 
ditions in this region should not be difficult to discover, diagnose, 
and remedy. 

The anus is peculiarly susceptible to injury and disease. First, 
because its lining membrane, being neither skin with its tough 
resisting power nor mucous membrane with its generous vascular 
supply, but a sort of transitional tissue, neither one nor the other, 
is easily injured. Secondly, any lesion occurring in this region 



232 



DISEASES OF THE RECTUM 




Fig. 165. — Specimen from partial colectomy for multiple colonic polyposis. 



RECTAL POLYPI ANAL PAPILLiE CRYPTITIS 



233 



Fig. 166. — Specimen from total colectomy for multiple polyposis. 



234 



DISEASES OF THE RECTUM 



has a small chance of recovery because of its meager blood sup- 
ply, and its constantly changing position, and because of trauma 
and infection from the contents of the bowel which are con- 
stantly passing over it. 

In order to understand more intelligently the condition under 
discussion, it might be well to say a few words about the normal 




Fig. 167. — Sectional view of the anal canal showing hypertrophied anal papillae and crypts 

of Morgagni. 
C. Opening of crypts of Morgagni. 
P. Hypertrophied papilla?. 
N. Normal papilla. 

anatomy of the anal papillae (Fig. 164). These papillae occur as 
an irregular line of small saw-tooth-like projections encircling the 
point of the juncture of the anus with the rectum, sometimes called 
the linea dentata. These papillae, varying in number from Rye to 
a dozen, are usually situated at the edges of the semilunar anal valves 



RECTAL POLYPI ANAL PAPILL/E CRYPTITIS 



235 



which guard the crypts of Morgagni. Andrews considers these 
papillae the normal tactile organs of the rectum and endowed with 
a special rectal sense. They have an abundant nerve supply, which 
accounts for the many reflex disturbances which originate when 
they are diseased. 

Examination and Diagnosis. — In making a digital examination, 
unless one is rather expert, these papillae are not always evident 
to the touch, but are apt to be overlooked unless an ocular in- 
spection is made. When diseased, these papillae may vary in size 




Fig. 168. — Hypertrophic d anal papillae. This well shows the appearance of the anal papillae 
when the anal margin is put upon the stretch by strong traction. 



from a quarter of an inch in length, by the same breadth at the 
base, to an inch and a quarter or an inch and a half in the longest 
diameter (Fig. 167). They are composed largely of an overgrowth 
of normal tissue. By everting the anus, the tips, and often 
all of the hypertrophied papillae themselves, can be brought into 
view (Fig. 168). They are of a pinkish color, slightly paler than 
the normal mucous membrane of the rectum. 

A distinguishing point between hypertrophied papillae and 
polypi is the fact that the hypertrophied papilla is always wider 



236 



DISEASES OF THE RECTUM 



at its base than the apex, while the polypus is always larger than 
the pedicle by which it is attached. The polypns is usually rounded 
or oval in shape, while the papilla is more or less triangular, or 
ribbon-shaped. Enlarged papilla? have been incorrectly designated 
as connective-tissue piles. They never show the characteristic 
varicose appearance of the internal hemorrhoid and are attached 
at the anorectal line. 

Containing some erectile tissue, on examination through the 
anoscope they will often be seen to stand out at right angles from 




Fig. 169. — Proctoscopic view of an aggravated case of hypertrophied anal papillae. 

the mucous membrane, giving the anal canal at this point a 
fringed appearance (Fig. 169). Many a surgeon, when he can 
discover no pathological lesion but finds a tight sphincter, over- 
looks what he may call "little tags of the mucous membrane." 
These are very frequently the cause of the tight sphincter, for 
let it be said here that no sphincter is abnormally tight unless 
there is some pathological lesion causing it, and a simple divul- 
sion of the sphincter will not relieve the symptoms, as many a 
surgeon and patient have found to their chagrin and disappoint- 
ment. 



RECTAL POLYPI ANAL PAPILLA CRYPTITIS 237 

Symptoms. — These papillae, being situated on the edges of the 
semilunar valves, are pushed and dragged downward during the 
passage of feces, which are more firm and harsh than normal. 
At each bowel movement there is a further pull and drag on the 
papilla, which is gradually stretched and hypertrophied. After 
it has become sufficiently hypertrophied, it will not retract at 
once after a movement, but will remain in the grasp of the ex- 
ternal sphincter, causing the sphincter to contract. This contrac- 
tion gradually becomes more tonic, and eventually we have what 
has been called the "tight contracted sphincter." This gives rise 
to one of the most characteristic symptoms of hypertrophied papillae 
— that of an unsatisfied feeling after stool — a feeling as if some 
particle of fecal matter were still in the grasp of the sphincter and 
could not be expelled, also a feeling of irritation and uneasiness, 
short of itching. As one patient described it to me, "It felt like 
the bite of seme small animal," and he was sure that he had a 
tapeworm, because he "could feel it nibbling at the anus." An- 
other stated that it felt like a bur, held in the grasp of the sphincter. 
This feeling can be immediately relieved by the insertion 
of the lubricated finger and pushing up and replacing the en- 
larged papillae which will be found in the grasp of the external 
sphincter. If they are left to themselves, it will often take from 
fifteen minutes to an hour and a half for them to gradually retract, 
when symptoms will entirely disappear. They cause spasm of the 
sphincter, and the constantly repeated spasms bring on a hyper- 
trophy of the circular muscular fibers, forming the sphincter mus- 
cles, and the hypertrophied sphincter is the so-called "tight sphinc- 
ter." 

Another symptom which the hypertrophied papillae cause is so- 
called neuralgia of the rectum, being transferred and transmitted 
pains from the pressure on the nerve-endings of the papillae. One 
of the most common symptoms, hoAvever, for which hypertrophied 
papillae, are responsible is pruritus ani. I do not wish to be misun- 
derstood as saying that hypertrophied papillae are the commonest 
cause of pruritus ani, because the causes are legion — but they are 
a common and frequently overlooked cause. 



238 DISEASES OF THE RECTUM 

CRYPTITIS 

It will be remembered that each papilla is found at the edge 
of a semilunar valve, which semilunar valve is the outer boundary 
of one of the crypts of Morgagni, also known as rectal pockets or 
mucous crypts. These crypts, whose function is not thoroughly 
understood as yet, become clogged with fecal matter, which on 
account of the shape of the crypt or sac is not readily expelled. 
The enlarged anal papilla overlying the crypt assists in prevent- 
ing its escape. The decomposition of this fecal matter or retained 
secretion, and the consequent irritation of the crypt, set up an 
inflammation or cryptitis, which may frequently go on to pus for- 
mation. The accumulated discharge originating here overflows from 
the crypt, and as it runs down the mucous membrane of the anus, 
sets up an irritation, which is made manifest by itching or pruritus, 
and the moisture complained of by many patients suffering from 
pruritus will be found to originate from this source. 

The feeling of uneasiness following stool, of which some pa- 
tients complain, is unlike that produced by any other condition. 
It has been described to me by one patient as a feeling as if he 
had thorns or pine needles in the anus — a sort of prickling sen- 
sation — not painful, but very uncomfortable ; and he would find 
himself constantly shifting from side to side as he sat in a chair. 
Occasionally the shifting would relieve him, when assisted by some 
pressure on the anus, thus releasing the papillae from the grasp of 
the sphincter. 

It is not only the extremely long papillae for which we must 
look to cause these symptoms, as those which are only half an 
inch in length, the tips of which are just engaged in the sphincter, 
are sufficiently enlarged to cause symptoms. 

Another condition which has been found to follow the hyper- 
trophy of an anal papilla is anal fissure. This is caused, as has 
been demonstrated by Wallis, of St. Mark's Hospital, London, 
by sufficient pressure during stool to tear the papilla downward 
from the edges of the crypt, and as succeeding stools continue 
the tearing process, the edge of the crypt is brought down to 
the outside of the anus, leaving in its wake a raw, ulcerated 
furrow (Fig. 80), which is traumatized further by each stool, and 



RECTAL POLYPI ANAL PAPILLA CRYPTITIS 239 

gives rise to the many severe and intolerable symptoms attending 
anal fissure. 

Treatment. — The treatment of this condition is extremely sim- 
ple and consists in the removal of the papillae when they are en- 
larged and the opening and cauterization of the crypts when in- 
flamed or infected. Both conditions are present together so often 
that their treatment will be considered together as well. The 
removal of papillae is accomplished in the following manner : 

The anoscope, or fenestrated speculum, is inserted, with the 
opening directed toward the lowest papilla to be removed. The 
papilla is injected at its base with y 2 per cent solution of apothesin 
or eucain, and distended to whiteness. After waiting five minutes, 
the papilla is removed as close to its base as possible by means 
of the snare. It is never necessary to anesthetize the sphincter, 
and oftentimes the anoscope or speculum is not required. By ever- 
sion of the anus (Fig. 168), the papilla may be brought into view 
and anesthetized and removed while thus exposed. 

No dressing is required, the hemorrhage, which is slight, soon 
ceases, and no after-care is necessary, other than that employed 
following the operation for simple fissure. 

When one of the Morgagnian crypts is inflamed, the area sur- 
rounding the crypt, including the papilla, should be injected and 
distended with the % per cent solution of aposthesin or eucain, and 
a V-shaped incision made from above — the base being at the mouth 
of the crypt and the apex one-half inch below its center. This in- 
cision should be deep enough to open well the crypt. The flap, 
which includes the papilla, is removed, and its base cauterized 
with a saturated solution of silver nitrate. A suppository con- 
taining two grains each of chloretone and thymol iodid and five 
grains of quinin and urea hydrochlorid is then inserted. Where 
more than one crypt is involved, the same technic is employed for 
all, the lowermost crypt being operated first, and the others in- 
jected just before operating. Where a crypt is acutely inflamed, 
without an enlarged papilla, the simple incision with the author's 
cryptotome (Fig. 121), or similar instrument will suffice. The after- 
care is the same as has been described for hypertrophied papillae. 



CHAPTER XII 

PROCTITIS AND SIGMOIDITIS 

This consists of a catarrhal inflammation, either acute or chronic, 
affecting the mucous membrane lining of the rectum, sigmoid 
flexure, or entire colon. There are many varieties of inflammation 
affecting the rectum and sigmoid due to the invasion by the micro- 
organisms of gonorrhea, syphilis, diphtheria, erysipelas, and dys- 
entery. With the exception of the last-named variety, the inflam- 
mation caused by the micro-organisms of dysentery, the other va- 
rieties accompany or are caused by diseases affecting other organs 
and occur as a complication, and will not be described in this chap- 
ter. Amebic dysentery will be discussed fully in a separate chapter. 
The author, therefore, will limit himself to discussion of simple 
catarrhal proctitis and sigmoiditis, acute and chronic. 

ACUTE PROCTITIS AND SIGMOIDITIS 

Etiology. — This disease occurs at all ages, children being af- 
fected as frequently as adults. Among the predisposing and causa- 
tive factors are sudden changes in climate, weather, or mode of 
living; the ingestion of highly seasoned foods, condiments; and 
excesses in the use of alcohol or tobacco. Constipation is occa- 
sionally a causative factor, but the presence in the rectum of in- 
testinal parasites, impacted feces, or foreign bodies, as well as in- 
fection of the rectum, from unclean enema tips or examining 
instruments, are more often responsible for its onset. Patients 
suffering from "rheumatism" and gout or those who are peculiarly 
susceptible to sudden chilling of the skin surface are particularly 
liable to attacks of acute catarrhal proctitis. Acute indigestion, 
with its attendant fermentation of food products in the intestinal 
tract, and ptomaine poisoning are very prolific sources, and inflam- 
mation by extension from any acute pelvic disorder is not uncom- 
mon. The use of drastic cathartics is also an etiologic factor 
of no small importance, and the ingestion of many food articles, 

240 



PROCTITIS AND SIGMOIDITIS 241 

which in some individuals causes urticaria of the skin surfaces, 
will often be responsible for an attack of acute catarrhal proctitis. 
Symptoms. — Its onset is attended oftentimes by a chill, slight 
rise of temperature, and a sense of uneasiness in the rectum and 
lower abdomen; oftentimes accompanied by backache, particularly 
over the sacral region, and occasionally shooting pains down the 
limbs. This is followed in a few hours by a sense of fulness and 
heat in the rectum, with a constantly increasing desire for stool. 
Disturbances of the bladder are noted, particularly a desire to 
urinate frequently and a burning sensation while doing so. The 
patient is most comfortable lying on his side. The movements be- 
come soft, and frequent evacuations occur. At first the move- 




Fig. 170. — De Vilbiss spray tube, provided with an adjustable tip so that the spray may be 

thrown in any direction. 

ments are those of ordinary diarrhea ; after the first day or so, the 
movements consist more largely of feces mixed with mucus and 
sometimes tinged with blood. If the disease progresses and ul- 
ceration occurs, the movements contain blood and pus, and a mu- 
copurulent discharge will be noted at the anal orifice between move- 
ments. In children, this condition frequently brings about pro- 
lapse of the rectum, and occasionally also in adults. 

Diagnosis. — With the history of an onset, such as has been 
given above, examination of the rectal cavity is indicated. With 
the patient in the knee-shoulder position the proctoscope should 
be inserted, and the rectum inflated. If the insertion of the 



242 



DISEASES OF THE RECTUM 



proctoscope is accompanied by considerable pain, as it will be in 
many cases suffering from proctitis, the sphincters should be first 
anesthetized according to the technic outlined in Chapter XV. 
The appearance of the mucous membrane of the rectum is some- 
what characteristic. Upon ocular examination, the rectal mucous 
membrane is bright red in color, its appearance being not unlike 
that of the inflamed conjunctiva, the difference being that the 
rectal mucous membrane will be more of a brick-red color, and 
the mucous membrane appears somewhat velvety and edematous. 
An increased quantity of stringy, yellowish mucus will be noted. 
The blood-vessels of the rectal wall, and particularly on the valves 
of Houston, will be found deeply injected and clearly outlined, 
standing out distinctly from the red mucous membrane. 




Fig. 171. — Author's rectal spray tube. 



Treatment. — The treatment of acute catarrhal proctitis is die- 
tetic, systemic, and local. In those cases depending for their 
origin upon the presence in the rectum or sigmoid of impacted 
feces or foreign bodies, their removal is first indicated. Where 
the proctitis is caused by ptomaine poisoning from decomposition 
of food material in the intestinal tract, prompt and free catharsis 
is the first essential. Patients suffering from systemic or consti- 
tutional diseases in whom the proctitis is merely a complication 
should of course receive general medical treatment for the under- 
lying constitutional or systemic trouble. 

Where irritating or improper food material is the causative 



PROCTITIS AND SIGMOIDITIS 



243 



factor, or the indulgence in alcoholic stimulants or tobacco in excess 
is responsible, their interdiction and withdrawal are obvious. 

In the local treatment of acute catarrhal proctitis, copious ir- 
rigations of the rectum, sigmoid, and colon with normal saline 
solution, at a temperature of 110 to 115° F., given two or three 
times during the twenty-four hours, has in many cases been suffi- 
cient. 

In irrigating the colon, the positions in which the best results 
are achieved are the knee-shoulder, left lateral or Sims', or the 
lithotomy. Where either of the last two positions are employed, 




Fig. 172. — Spraying the rectum with the patient in the knee-shoulder position. On 
account of the ballooning of the rectal cavity by air inflation in the knee-shoulder position, 
this position is ideal for the application of sprays to the rectal surfaces. 



the hips should be elevated considerably higher than the head 
(Fig. 181). The irrigator, or fountain syringe, to be placed from 
one and a half to two feet above the level of the anus, and the 
flow checked by pressure on the tubing, when there is a desire on 
the part of the patient to expel the fluid before a sufficient quan- 
tity has been administered. This uncomfortable feeling is due to 
the overdistention of the bowel at certain points when the inflow 
is interrupted by either the normal sacculations or spasmodic con- 
traction of the circular muscular fibers. This sensation will soon 
pass away, however, if the inflow is checked for a moment so as 



244 



DISEASES OF THE RECTUM 



to allow the solution already in the bowel to now higher np. Chang- 
ing the position of the patient from one side to the other and 
massaging the abdomen gently will greatly assist in the distribu- 
tion of the irrigating fluid. By this method, the majority of pa- 
tients will be able to retain a sufficiently large amount of the irri- 
gating fluid to flush thoroughly the entire colon. 




Fig. 173. — Ulcer of the rectum. This case well illustrates the importance in proctoscopy 
of examining the cavity behind each rectal valve. In this patient the ulceration was 
situated on the right lateral wall of the rectum, and had not the first rectal valve been 
pushed aside by the proctoscope, its presence might have escaped unnoticed. 



In those cases Avhere the mucous discharge from the rectum or 
sigmoid is profuse, the use of nitrate of silver solution in strengths 
ranging from one to five per cent, by means of the rectal spray 
(Fig. 170), has been found very efficacious. The author uses a 



PROCTITIS AND SIGMOIDITIS 245 

nine-inch metal spray tube, which is attached to the hand atomizer 
or used with compressed air. Its distal extremity is closed, but 
from its circumference, about one sixteenth of an inch from 
the end, the solution issues in all directions from four small 
apertures, so that the solution is not thrown any higher into 
the bowel than one wishes, but 'bathes all surfaces alike (Fig. 171). 
The rectum and sigmoid are best sprayed with the patient in the 
knee-shoulder position (Fig. 172). In some cases, where the mucous 
flow appears to come from higher up in the bowel, irrigations of 
the colon with various astringent solutions are indicated. Two to 
five per cent solutions of alum answer very nicely, and the aqueous 
fluidextract of krameria, from five per cent to twenty per cent as 
advocated by Tuttle, has proved of value in the author's hands. 

While many authors advocate the confining of the patient in 
bed during the treatment of acute catarrhal proctitis, the author 
has found no difficulty in securing results by allowing the patient 
to be up and around for a greater portion of the day. He believes 
that better drainage of the intestinal tract is secured at all times 
by the upright position. In some cases where results are not 
obtained by spraying with aqueous solutions, and where there is 
a tendencj^ for the bowel wall to ulcerate, the insufflation of 
various powders will be found of great value — iodosyl, compound 
stearate of zinc with balsam of Peru or boric acid, and thymol 
iodid have all been found very satisfactory in these cases. 

Ulcerating spots should be treated with pure ichthyol or solu- 
tions of 5 per cent or 10 per cent of nitrate of silver. The author 
is not in sympathy with the use of solutions of the stronger chemical 
antiseptics, such as the bichlorid of mercury or carbolic acid, even 
when used in very weak solutions. He believes that more harm is 
accomplished by the action of the irritating chemical solutions 
on the Aveak and debilitated lining mucous membrane than what- 
ever little good they accomplish by their action as antiseptics. 

In irrigating or flushing the colon, the recurrent-floAV soft- 
rubber colon tube, devised by J. L. Jelks, of Memphis, Tenn., will 
be found a very useful piece of apparatus (Fig. 180). For the 
technic of its use the reader is referred to the following chapter. 
During the treatment of a case of proctitis or sigmoiditis, the pa- 
tient should be kept on a light and nonirritating diet in which the 



246 DISEASES OF THE RECTUM 

vegetable elements are largely eliminated. The thin cereal gruels 
prepared from oatmeal, rice, and barley, egg-albumen, the various 
flavored gelatins and liquid peptone solutions, as well as butter- 
milk, will be found best for use in these cases. The use of chocolate 
has also been found of great value as an addition to the dietary. 
Four to six ounces daily will take the place of an equal quantity 
of meat and leave less residue. Milk is contraindicated on account 
of its tendency to constipate, and the fact that it forms hard curds 
which only further irritate the already sensitive bowel. 

Internal medication is not of much avail; the use of five grain 
tablets of trimethol and ichthyol in 2 to 5 grain doses, given in 
double capsules four times daily, the author believes, has given 
some good results. He has found the employment of white re- 
fined petroleum oil to be of particular value in proctitis. It seems 
to have a specially soothing effect on the inflamed and irritated 
mucous membrane of the bowel, and while it does not produce or 
stimulate peristalsis, it causes easy and free evacuation by its 
mechanical softening and lubricating effect. Being a mineral oil 
of no food value and having no medicinal effect, it is not acted 
upon by the digestive secretions, and passes through the intestinal 
canal unchanged. 

The patient should be instructed to drink six to eight glasses 
of water daily ; if there is any doubt as to the purity of the water, 
it should be boiled and then kept in bottles on ice. In order to 
remove the flat taste of boiled water, the author would suggest 
that before use it be poured into an open vessel or pitcher and 
stirred up with a revolving egg beater. This aerates the water so 
that it again tastes fresh and clean, and effectually removes the 
unpalatable taste which is one of the drawbacks to the use of 
water sterilized by boiling. The use of flaxseed tea is often of 
assistance in these cases. If properly prepared, it is of distinct 
value. A good way to prepare flaxseed tea is as follows: Take 
four or five tablespoonfuls of whole flaxseed and place in a shal- 
low pan. Pour over this a .quart of boiling water, place the pan 
over the flame and allow to boil for five minutes, then strain 
through muslin and allow it to cool. It is best kept on ice until 
ready to use. If it is desired to sweeten or flavor the flaxseed 
tea, lemon juice, oil of peppermint or wintergreen, and sugar may 



PROCTITIS AND SIGMOIDITIS 247 

be added in quantities to taste while the tea is still hot. A tea- 
cupful should be taken as hot as can be comfortably borne every 
night at bedtime. This will often act as a mild laxative and 
seems to have some soothing influence on the mucous membrane 
of the bowel. 



CHRONIC PROCTITIS AND SIGMOIDITIS 

This disease is usually of two varieties, hypertrophic and atro- 
phic. The atrophic variety is the most common variety of chronic 
proctitis or sigmoiditis. The hypertrophic variety may follow 
an attack of acute proctitis or sigmoiditis but is often produced 
by other diseased conditions outside the bowel. Pressure from 
abdominal tumors, movable kidneys, uterine displacements, exten- 
sion from pelvic cellulitis, and adhesions following inflammatory 
conditions of the pelvis may all set up attacks of hypertrophic 
proctitis and sigmoiditis. Appendicitis has also been noted as an 
etiological cause. 

The atrophic variety may often be brought about by a long 
period of chronic constipation, the abuse or excessive use of ca- 
thartics extending over a long period of time, excesses in both 
eating and drinking, particularly in people of sedentary habits. 
Other causes of a more local nature are repeated attacks of fecal 
impaction, the enema habit, foreign bodies in the rectum and un- 
natural practices. 

Chronic Hypertrophic Proctitis. — This variety is distinguished 
from the atrophic variety by the fact that the mucous membrane 
and submucosa are always thickened, and the glands as well as the 
interglandular connective tissue hypertrophied and increased. The 
anal papillae are usually very much enlarged in this condition. On 
proctoscopic examination the appearance of the mucous membrane 
is somewhat characteristic. Tuttle well described it as follows : 

Through the proctoscope it appears edematous, paler than usual, and covered 
with a thin coat of whitish secretion. The swollen membrane bulges out into the 
fenestra of the conical speculum or falls down and completely covers the end of 
the proctoscope. When the mucopus is wiped off, the membrane presents through 
the magnifying glass a cauliflower-like appearance, whitish and granular. It does 
not bleed easily, and the end of a fine probe being pressed down upon its surface, 
the tissues will meet together above it. By scraping with a rectal scoop one may 



248 DISEASES OF THE RECTUM 

obtain a certain amount of mucopurulent fluid, consisting of pus-cells, leucocytes, 
and various bacteria, together with small masses of fecal matter and undigested 
particles of food. 

Symptoms. — The disease may be of insidious onset, or it may 
be the continuation of an attack of acute catarrhal proctitis. The 
patient is usually in a run-down condition, and presents the usual 
symptoms of such a state, such as impaired appetite, foul breath, 
indigestion, gaseous eructations, diarrhea, occasionally alternat- 
ing with constipation, a frequent desire to defecate without much 
result, and . an unsatisfied feeling as if something more were to 
pass away after the stool. Where the passages are loose, the 
stools are inclined to be of a pea-soup consistency, consisting quite 
largely of mucopurulent material, or there may be small hardened 
boluses or scybala covered with sticky mucus, or mucopus. On 
account of the hypertrophied condition of the mucous membrane, 
prolapse is met with in some cases, and pruritus ani is a frequent 
symptom. The secretion keeps the region of the sphincter con- 
stantly moist and is occasionally so profuse and constant that the 
patient has to wear an absorbent dressing to prevent it from soil- 
ing the clothes. On account of the constant moisture of the part, 
condylomata are occasionally found, particularly at the posterior 
aspect of the anus and anal canal. 

Diagnosis. — The diagnosis is made upon proctoscopic and sig- 
moidoscopic examination. The characteristic hypertrophied ap- 
pearance of the mucous membrane, with the presence of muco- 
purulent discharge, with or without ulceration of the mucous 
membrane, accompanied by a history of symptoms such as have 
been given above, should make the diagnosis not difficult. The 
condition is, fortunately, not very common. 

Treatment. — If upon examination of the patient such extrarectal 
causes as appendicitis, floating kidney, or abdominal or pelvic 
growths impinging upon the bowel are discovered, the indicated 
surgical measures for their relief should be carried out. The pa- 
tient's dietary should be corrected, and all condiments, alcoholic 
stimulants, pastries, salads, sweets, fresh fruits, and freshly baked 
foods prohibited. 

In order to give as little work to the intestines as possible, 
the patient should be put on a diet which is largely assimilable: 
such as, eggs, buttermilk, gelatins, chocolate, lean meat, poultry, 



PROCTITIS AND SIGMOIDITIS 249 

freshwater fish, and small quantities of green vegetables, such, as 
spinach, beet tops, lettuce, endive, and kale. The patient should 
be encouraged to drink large quantities of cold water and should 
try to have a bowel movement at regular hours. Liquid petrolatum 
in doses varying from one to four drams three or four times a 
day should be administered, on account of its soothing influence 
upon the mucous membrane of the intestinal tract, and because 
by its admixture with the feces it prevents the formation of hard, 
irritating masses. 

Where symptoms of intestinal indigestion are present the author 
has found pancreatin in ten-grain doses, taken with or directly 
following the meal, of considerable value. Ichthyol in double cap- 
sules, in doses of from iavo to five grains four times daily, seems 
to be of some service. Trimethol in 5-grain enteric tablets, ad- 
ministered four times daily, is useful. The bowels should be flushed 
morning and night with some astringent solution, such as is used 
for the treatment of acute catarrhal proctitis. Tuttle recommends 
very highly the use of one to three quarts of a two to ten per cent 
solution of aqueous fluidextract of krameria. This is best given 
with the patient in the knee-shoulder position and through a Jelks' 
recurrent-flow colon tube. The preparation of the aqueous fluidex- 
tract of krameria is described by Tuttle as follows : 

Macerate one pound of bark of krameria in a long percolating tube for twenty- 
four hours. After this a mixture of 20 per cent glycerin and 80 per cent water is 
allowed to percolate through it. The percolate should be constantly stirred and 
refiltered through the bark the second time. The filtrate is then evaporated down 
to one pound, thus obtaining an aqueous fluidextract, containing grain for grain 
all the therapeutic properties of the bark. The preparation should be kept in a 
dark place and not exposed to the air. 

If, on proctoscopic or sigmoidoscope examination, localized ul- 
cerated areas (Fig. 173) are discovered, they should be sprayed 
with a 1 to 3 per cent solution of nitrate of silver or 5 per cent 
solution of ichthyol. They may be stimulated by the application 
of nitrate of silver, 10 per cent, or pure ichthyol or balsam of 
Peru, using a long-handled applicator. The general condition 
of the patient must be improved by ordinary, tonic measures and 
the encouragement of moderate exercise in the open air and sun- 
shine. 

Chronic Atrophic Proctitis and Sigmoiditis. — This variety is more 



250 DISEASES OF THE RECTUM 

common than the hypertrophic, and consists of a general atrophy 
of both the glands and intraglandular structures of the rectum 
and sigmoid. It differs from the hypertrophic variety in that it 
does not frequently extend higher than the sigmoid flexure, and 
there is a thinning or destruction of the mucous membrane lining 
of the bowel. The pathology of the condition is well described by 
Tuttle as follows: 

One observes upon examining the mucous membrane in these cases an irregular, 
bosselated, or granular appearance. The surface is dry, rough, inelastic, and with- 
out any salient vegetations. Attached to the surface here and there are small 
masses of dry fecal material, and occasionally little islands of necrotic epithelium 
or pseudomembrane. 

Microscopic examination shows the epithelium absent in many places, but 
always present in the deeper portions of the crypts of Lieberkiihn. These follicles 
are generally atrophied, the intratubular tissue decreased, and their goblet-cells are 
few in number. The cylindrical epithelium is said to assume the stratified pave- 
ment type in this disease. This change does not extend more than one or two 
centimeters above the anorectal line; it is confined to the superficial structure of 
the membrane, and does not involve the tubules. 

The connective tissue of the submucous coat is dense and slightly thickened; it 
does not contain embryonic tissue and elastic fibers, as in the hypertrophic form. 
The solitary follicles are often enlarged and distended. At points there are dis- 
tinct granulations, and ulcerations, accompanied with hyperemia and multiplica- 
tion of the blood-vessels, but there is no alteration in the blood-vessel walls. 

Symptoms. — As has been stated, this condition supervenes fre- 
quently on an old long-standing case of constipation. The stools 
are small, hard, and dry, and their passage is painful; they are 
often streaked with blood, pus, and mucus. The patient suffers 
from tenesmus, referred pain in the sacral region and down the 
legs. The rectum feels hot, and after stool it feels as if it were 
not emptied. This feeling is not like the sense of fulness which 
is more characteristic of the hypertrophic variety; but more a 
sense of uneasiness which focuses the patient's attention upon 
the rectum, which makes him feel that the emptying of the rec- 
tum will bring him relief. Pruritus ani is a frequent symptom as 
well, as is spasm of the sphincters. On account of the contracted 
condition of the anal canal, the passages are frequently followed 
by the production of small fissures or cracks in the mucous mem- 
brane. Their presence adds a stinging or burning sensation to 
the other symptoms of the disease. These fissures are very super- 
ficial and are not to be confounded in any sense with the true 



PROCTITIS AND SIGMOIDITIS 251 

or typical anal fissure. They consist merely of linear abrasions 
in the lining membrane of the anal canal, and lack any tendency 
to chronicity which is characteristic of a true fissure. Hemor- 
rhoids are said to be found frequently accompanying this con- 
dition. 

With the patient in the knee-shoulder position, proctoscopic ex- 
amination shows the mucous membrane to be reddened, but not 
markedly as in the acute variety, dry, covered here and there with 
small flecks of dry fecal matter. The insertion of the proctoscope 
is usually accompanied by some hemorrhage due to the passage 
of the instrument. On examination of the rectal walls numerous 
pin-point ulcerations are met with. The mucous secretion, which 
is very slight in this condition, clings to the bowel wall, and is 
characterized by thickness and tenacity. In this variety the mu- 
cous membrane does not fall together before the proctoscope, and 
the rectum gives the appearance of being a stiff tube, while the 
rectal valves stand out very markedly. Ulcers other than the 
pin-point variety are not uncommon, and tend, when present, to 
become chronic and gradually to encircle the bowel, producing 
a strictured condition. 

Treatment. — In this condition the presence or absence of syphilis 
should be ascertained. Where either from the ignorance of the 
patient of his true condition or from his reticence about the mat- 
ter one cannot obtain a definite history,- the Wassermann test, or 
serum diagnosis, should be resorted to. If positive, the ordinary 
measures for the treatment of syphilis in the third stage should 
be employed, the intravenous administration of salvarsan being 
of the greatest value in those cases. 

The diet is exactly the same as that outlined for hypertrophic 
proctitis, with the exception that the patient may have fatty food, 
bread (not freshly baked), toast, rice, sago, and custards. Where 
intestinal indigestion is present, pancreatin should be administered 
and liquid petrolatum given, as outlined in the treatment of the 
hypertrophic variety. As this condition is usually confined to the 
rectum and lower sigmoid, the high irrigations will not be neces- 
sary, but the solutions mentioned are equally applicable for the 
flushing of the sigmoid and rectum in this variety. After irrigat- 
ing the rectum, the patient should be put in the knee-shoulder 



252 DISEASES OF THE RECTUM 

position, and under the guidance of the eye, ulcerated patches on 
the mucous membrane should be touched up through the proctoscope 
with two to five per cent solution of nitrate of silver, iodin, or 
pure ichthyol. Ichthyol in five per cent aqueous solution is very 
valuable as a spray in this condition, as is the fluidextract of 
krameria in strengths ranging from twenty to thirty per cent. 
The treatment of the accompanying conditions, such as fissures, 
hemorrhoids, and pruritus, should be carried out as outlined under 
the respective chapters. What has been said before regarding ex- 
ercise and fresh air is equally applicable in this condition. 

Do not commit the grievous error of treating a patient for a 
localized proctitis or sigmoiditis when the disease affects the whole 
colon. While mild cases of colitis will respond to the treatment 
outlined in this chapter, many cases of colitis Avill require physio- 
logic rest, and this can only be accomplished by cecostomy or tem- 
porary colostomy. Colonic irrigations from above may also be re- 
quired before a cure can be effected. 



CHAPTER XIII 

DYSENTERY 

By John L. Jelks, M.D., F.A.C.S., Memphis, Tenn. 

GENERAL CONSIDERATIONS 

Synonyms. — Colitis, die rote Ruhr, or Dysenteric (German), Diffi- 
cult as int est inorum (Latin), Ava hrepov (Greek). 

Definition. — An acute or chronic inflammatory disease, usually 
affecting the large intestine, beginning in the rectum, but some- 
times extending into the small bowel. In the acute form it is 
characterized by pain, tenesmus, and frequent passages of bloody 
mucus. In the chronic form the patient suffers recurrent at- 
tacks of diarrhea alternating with constipation. 

Historical. — Dysentery was one of the best known diseases of 
antiquity. Even before the time of Hippocrates, reference to it 
was made, the earliest being that found in the papyrus of Ebers. 
Hippocrates, in the year 460 B. G, was the first writer to give a 
fairly accurate description of its symptomatology, pathology, and 
sequelae. 

Other well-known writers Avere Celsus, the medical Cicero of 
his day (45 A. D.), Aretaeus, Galen, and Alexander of Tralles. 
Then for more than a century little further knowledge was im- 
parted until the time of Antonio Benivieni (1506), and Thomas 
(1833), who refuted many of the erroneous ideas of his prede- 
cessors. Woodward (1879) gave a most excellent history of 
this disease. 1 Kartulis, in Egypt (1885), Flexner (1890), Coun- 
cilman and Lafleur (1892), Shiga, of Japan (1879), Strong and 
Musgrave, McDill, of Manila, and Harris of Atlanta, of the present 
era, have contributed perhaps the most valued writings. Osier, 
Tuttle, and Surgeon General Sternberg, of the United States Army, 
are also among those who have furnished data in our own country. 

The author of this chapter has also made close study of this 
disease in the Southern states. 



^ledical and Surgical History of the War of the Rebellion, Vol. 2. 

253 



254 DISEASES OF THE RECTUM 

Geographical Distribution. — Dysentery does not respect any 
country, climate, or race. Ayers very truthfully states that where 
man is found there some of its forms appear. A. Hirsch says 
that it has a wide distribution, over the inhabited earth at all 
historic times. It is without doubt one of the four great epidemic 
diseases of the world. In the tropics its ravages have been most 
deadly, destroying more lives than cholera, and to the armies 
it has been more destructive than powder and shot (Osier), and 
it has been shown that the ameba is the prevailing etiologic fac- 
tor in the disease as observed in the Southern states. Dysen- 
tery is a destructive giant compared to which strong drink is a 
mere phantom (McGregor). The worst outbreaks occur as en- 
demics in the tropics and decrease as we leave this latitude, while 
in the higher latitudes it seldom appears in this type, though now 
and then in greater or less epidemics. A very striking fact relative 
to this affection is that it involves the cold zones. Epidemics have 
been reported in Alaska, Sweden, Russia, Greenland, and Iceland, 
also other of the colder countries. 

General Etiology. — Season. — Among the predisposing causes 
season is the most important. More cases of dysentery are found 
during the summer and autumn months. This is due to several 
reasons. Sudden changes in temperature, especially sudden rises, 
have a most marked effect. It is most prevalent in the warm 
climates, and as stated above, it is most deadly in the tropics. 
Therefore, climate should be mentioned as one of the causative 
factors. 

Race. — Race itself does not seem to affect this disease. Strange 
though it may seem, the negro race in the South has not seemed 
to suffer much, with reference to this disease ; notwithstanding 
the baneful consequences of poor hygienic conditions, as over- 
crowding, improper food, poor ventilation, filth, thin clothing, and 
especially syphilis — a disease almost universal among this race, 
either inherited or acquired. These, however, must all be in- 
cluded under predisposing causes. 

Sex. — Under etiology, we should also mention sex. Within our 
experience, which is not at variance with that of other writers, 
dysentery is much more common among males. 

Poor Hygiene. — In the slums of our cities, where filth abounds 



DYSENTERY 255 

and where proper sewerage is lacking, we find more cases of dysen- 
tery than in the sections where the hygienic conditions are better. 
Many cases are found in institutions, such as insane asylums, bar- 
racks, jails, and army camps. Wherever there is overcrowding, 
there is very likely to be found a large percentage of dysenteric 
cases. During the Civil War, Woodward reported 259,071 cases 
of acute dysentery, and 28,451 of the chronic form, in the Federal 
service alone. In the Marne counter-offensive in July and August, 
1918, thousands of cases of the bacillary type occurred among the 
troops of the American Expeditionary Forces. The disease was 
definitely proved to be fly-borne. 

Topography and Condition of Soil. — Investigators have tried to 
associate dysentery with certain topographical conditions, or with 
conditions in the soil, but have been unable to do so. 

Epidemics have proved more fatal in the country than in the 
city. 

Soil that is badly contaminated with dysenteric excreta is a 
great source of infection. Czernicki tells about dysentery break- 
ing out in two French squadrons in 1875 that were on the same 
ground occupied a short time previously by a cavalry regiment 
which had been affected with the same disease. 

The writer has often found nests of dysenteric cases in the 
low flat mill districts of the city, and in marshy lowland sections 
of the country. No doubt, owing to the character of the soil in 
these localities, seepage contamination of drinking-water sources 
sometimes occurs. Houses built upon a low damp soil are un- 
sanitary, and when the surrounding soil always remains saturated 
with moisture, there exists a favorable condition for the develop- 
ment of dysentery. The peculiar emanations from soil of this kind 
have always been considered very harmful. It is thought that 
they have a depressing influence upon the inhabitants, and thus 
make easier the inroads of diseases. 

In one ill-drained district of Memphis, the author has treated 
many cases of amebic dysentery within a radius of two blocks, 
and other cases were treated that had been infected in the same 
territory. It is also an interesting fact to note here that two families, 
in which were four of the patients, purchased vegetables from the 
same Italian huckster. 



256 DISEASES OF THE RECTUM 

There is yet another reason why we find more cases in marshy 
lowland districts. Here we find the greatest growth of vegeta- 
tion, which, when conditions are favorable, furnishes a most suit- 
able nidus for the propagation and development of amebas, bac- 
teria, and other micro-organisms. 

Foods. — Certain articles of food are unquestionably predisposing 
causes of dysentery. This fact is not due so much to an idiosyncrasy 
to some particular foods, but mainly to the microorganisms which 
they contain, and to the putrefactive changes which occur within 
the intestinal tract. All groundling vegetables and fruits, espe- 
cially those shipped from the tropics, and from infected districts 
are possible sources of infection. 

Undoubtedly infections with the amebas have been traceable to 
eating such vegetables as lettuce, strawberries, cress, and potatoes. 

Amebic, flagellate and pellagrous diarrheas have been directly 
traceable to infected gardens and homes wherein antecedent cases 
had been treated months and even years before. 

Eating food in excess, and the resulting attacks of indigestion, 
often pave the way for dysentery. 

Drinking Water. — The author has given much thought to water 
supply as a medium through which dysenteric infections are con- 
veyed. This is undoubtedly the most common source. "We have 
been impressed by the fact that many cases are found among 
sportsmen, also timbermen who spend much of their time in the 
woods, and who drink, when necessity requires, from surface pools, 
springs, and slashes. 

The author has treated cases of amebic dysentery from a country 
district with which he is quite familiar, and has knowledge of the 
fact that the disease was contracted in the same infected neighbor- 
hood in which twenty years previously another case has lived, which 
proved fatal. The fact has been elicited that many of the author's 
cases had neighbors who were suffering in like manner, and who 
were procuring their drinking water from the same source. 

There are certain rivers in China whose waters are known to 
cause dysentery. 

In 1863, the number of cases among the workmen construct- 
ing the Suez Canal was decreased when the better water of the 
Nile was used. 



DYSENTERY 257 

The author has treated one case of amebic dysentery in the 
person of a physician, who thinks undoubtedly that the infection 
was obtained from drinking Mississippi Eiver water while on 
board a river steamer. Thevenol says, ''Nothing is so prone to 
lead to disorganization of the large intestine as infected water." 
Impure water itself does not produce dysentery, but only when 
it contains the special micro-organisms. 

ACUTE CATARRHAL DYSENTERY OR SPORADIC 
BACILLARY DYSENTERY 

This form is the least severe and most common form that is 
encountered. It occurs both sporadically and endemically. This 
type is characterized by the frequent passage of great quantities 
of mucus. 

Etiology. — Children principally are infected with this form, but 
we often see it in adults, most often complicating other diseases. 
It is the kind of dysentery that accompanies all of the exanthemata. 
We see it, in fact, complicating almost all of the acute infectious 
diseases. Still another important cause is the ingestion of cer- 
tain kinds of foods, or other irritating substances. The ordinary 
attacks of enterocolitis in babies during the summer months come 
in this classification. Most of these attacks are due to milk poison- 
ing (bacterial and putrefactive changes). 

Pathology. — Macroscopically a superficial, acute inflammation in- 
volving the large intestine, but sometimes extending into the small 
bowel, is seen. The tendency of such cases is to recover without 
necrosis. Sometimes, though, in the more severe attacks, the mucosa 
will become injected to such a degree that small ulcerations occur. 
In these cases the mucus is often stained or streaked with blood. 

Microscopically, are seen the Bacillus coli communis, also the 
Trichomonas intestinalis, and Paramoscium coli, and occasionally the 
Cercomonas intestinalis. We also find red blood-corpuscles and 
leucocytes, and always large numbers of desquamated epithelioid 
cells, dotted about with fat globules and vacuoles. 

Symptoms. — The onset is sudden and usually ushered in by an 
attack of cholera morbus, or by an attack of acute indigestion. 
Sometimes a more or less distinct chill may occur at the onset. 

Nausea and vomiting are not rare symptoms. 



258 



DISEASES OF THE RECTUM 



The tongue has a moist coat at first but soon becomes dry. 

From the first there is diarrhea. Pain is complained of over 
the entire abdomen, also tenesmus, and severe griping pains. The 
patient is extremely restless and cannot get relief from a desire 
to stool. The bowel movements are at first free, and watery, or 
sero-sanguineous, but later on, contain only small quantities of 
mucus streaked or stained with blood, and have an offensive odor. 

A slight elevation of temperature usually accompanies this form, 
but in more severe cases, it may reach 103° F. There is cor- 
responding acceleration of the pulse, and the patient complains 
every few minutes of thirst. 

The stools, during the first day or two of the attack, contain, 
in addition to the above-mentioned materials, small fecal masses 
(scybala). Sometimes, during the course of the attack, the stools 
contain an excess of bile and cause intense burning while passing. 

The ordinary cases of acute catarrhal dysentery are self-limited, 
usually recovering in a week. Some are so mild that treatment is 
not sought, It must be remembered, however, that the cases which 
begin with mild symptoms may develop graver ones at any moment. 

Diagnosis.— The diagnosis is very easy. The cramping pains, 
tenesmus, and frequent passages of mucus and blood are posi- 
tively diagnostic. If, however, a case may be obscure, the micro- 
scope and proctoscope will at once clear it up. 

Prognosis. — In most cases the prognosis is favorable, but it is 
best to be guarded at all times in giving it, since some of the 
cases, which at first seem quite mild, may terminate adversely. 
Ordinarily, though, the symptoms will subside in a week, and 
the patient will recover rapidly. There is always rapid emacia- 
tion and weakness. 

DIPHTHERITIC DYSENTERY 

Definition. — This is an inflammation, usually confined to the lower 
part of the colon, and rectum, but sometimes extending into the 
small bowel. It is accompanied by a croupous, or true diphtheritic, 
exudation. It is one of the epidemic forms found in Japan, also 
in armies, in insane asylums, and ships, or wherever large numbers 
of people are crowded together. 



DYSENTERY 259 

Etiology. — This form of dysentery is caused by the Bacillus 
dysenteric?, discovered by Shiga in Japan (1897). Flexner and 
Strong encountered the same bacillus in one of the forms of the 
disease which prevails in the Philippines and Porto Eico. The 
bacillus is described by Shiga as being a short rod with rounded 
ends, and closely resembling the bacillus of typhoid fever. It 
possesses slight motility. Flexner discovered that the bacillus 
"is inactive to blood-serum from typhoid fever cases, but reacts 
with serum from dysenteric cases to which Bacillus typhosus does 
not respond." Shiga's bacillus may be found within the body as 
late as one year after the primary infection. 

Pathology.— The mucosa, if the attack is not severe, is coated 
with a yellow exudate. Slight ulceration of the mucous mem- 
brane over the tops of the folds of the colon is seen. 

In severe attacks, however, all the layers of the colon are in- 
volved, and it appears greatly enlarged. The infiltration is so 
great that extensive necrosis takes place. The mucous membrane 
over the entire colon presents a puffy or swollen condition, yellow 
in color. Large areas may slough en masse. 

Microscopically, this slough is found to consist of a fibrinous 
and cellular exudative coating over the mucosa. 

The glands of Lieberkiihn are destroyed, and sometimes no trace 
of them is found. 

Symptoms. — The symptoms are practically the same as those of 
acute dysentery greatly intensified. The onset is more severe. 
The chill is often present, and the fever is high, running an 
irregular remittent course. The pulse is greatly accelerated; 
tormina and tenesmus are most severe. 

Delirium is common. Bowel movements may at first be loose 
and watery. Soon great quantities of sero-sanguineous discharges, 
containing bloody mucopurulent material, and sloughs of variable 
sizes, are passed. The distention of the abdomen is greater, and 
pain is more severe. There is more rapid loss of strength. 

Diagnosis. — The diagnostic points of most value are the character 
of the dejections, which may contain pseudomembranes, severe 
symptoms, and the appearance of epidemics. 

The positive diagnosis is by the agglutination test. 



260 DISEASES OF THE RECTUM 

Complications. — Complications in this form are encountered more 
frequently. 

Perforations sometimes occur and are almost invariably followed 
by peritonitis. 

Liver abscess is another grave complication. 

Nephritis, phlebitis, pericarditis, endocarditis, and pleurisy have 
also been noted. 

Grave symptoms referable to the central nervous system, due 
to toxin poisoning, denote a complication of serious moment. 

Recovery sometimes takes place, but usually after a more or less 
chronic course. 

SECONDARY DIPHTHERITIC DYSENTERY 

The lesions of this form are similar to those of the last de- 
scribed, but not so severe. The secondary, as the name implies, 
usually follows one of the acute, or chronic, diseases, as pneu- 
monia, nephritis, pericarditis, endocarditis, pulmonary phthisis, 
typhoid fever, and numbers of other varieties. 

Symptoms. — The symptoms are sometimes not very noticeable. 
The griping pains and tenesmus are not very severe as a rule. The 
patient has about two to six loose bowel movements a day. Ana- 
tomically, the inflammation is very superficial, only the upper layers 
of the mucosa being involved. The inflammation may progress, pro- 
ducing more or less necrosis. Very little blood is found in the 
stools. 

Prognosis. — The patient will often perish. Owing to adynamia 
already existing, much resistance is impossible. 

FLAGELLATE DYSENTERY 

Etiology. — During the last fifteen years the author's attention 
has been drawn to the increasing prevalence of flagellate infec- 
tions, and during more recent years many cases of pure flagellate 
diarrheas have been observed. Many of these cases have been traced 
to their origin with a view of ascertaining the source from whence 
the infection came. In many instances Ccrcomona-Intestinalis- 
Hominis dysenteries have been as easily traceable to one or more 



DYSENTERY 261 

preceding cases in a neighborhood or home wherein the patient 
had visited, as could have been traced a typhoid fever infection. 

This form of dysentery is at present almost entirely confined to 
the warm and hot climates, and is very prevalent in the southern tier 
of the gulf states. The most prevalent form of the disease is 
that caused by the Cercomona-Intestinalis-Hominis, though other 
flagella may produce diarrhea. 

This organism invades the small intestines, is 16 to 20 microns 
long and 10 to 12 microns broad, or about one fourth the size of 
a pathogenic ameba. It is capable of very active motility and is 
propelled by its tail. 

These organisms are found in larger numbers after a dose of 
salts is given which causes them to be washed down into the large 
intestines. They produce pathology in both small and large in- 
testines. This pathology is very superficial when the infection is 
an unmixed one, amounting to congestion, erosion of the epithelium 
and an occasional ecchymosis or circinate abrasions. The stools, 
ten to thirty in number in twenty-four hours, are more like those 
of typhoid fever and of pellagra, and the gross pathology seems to 
be the same that I have observed in the acute diarrhea of pellagra. 

Treatment. — The diet must be free of carbohydrates, fresh vege- 
tables, pork, and pepper and other irritants. The diet I have found 
best is bulgarian buttermilk, sweet milk with lime water, junket, 
albumins, albuminous foods, chicken and other fowl, fish, beef, 
mutton and gluten bread. 

The usual treatments given are not sufficient to establish a cure 
of these cases. Repeated microscopical examinations after the 
administration of salts should be made before dismissal, for all 
symptoms may ha\ 7 e disappeared, only to return later, and such 
cases are carriers of the infection. 

Large doses of bismuth subnitrate, hexamethylenamin, zinc sul- 
pho-carbolate, ipecac and methylene are the remedies usually pre- 
scribed by the author. 

Treatment by the Trans-duodenal Route. — Treatment of these 
cases by the transduodenal route has given good results in some 
cases. Dr. Anthony Bassler, of NeAV York suggests the following 
solution to be used through the duodenal tube. 



262 DISEASES OF THE RECTUM 

Soda Sulphate 270 grams 

Soda Chloride 270 grams 

Water 900 c.c. 

Boil and filter 

Use 30 c.c. (1 oz.) to the liter of water. 

To this solution may be added methylene, two to five grains to 
the ounce. This method requires a technician and an equipment, 
also a patient who is willing to cooperate with the attendant. 

It is especially in this form of diarrhea and in the diarrhea of 
pellagra that there occurs a more or less severe colon bacillemia and 
bacilluria with grave toxic symptoms, in which the author has on 
numerous occasions used stock vaccines with almost negative re- 
sults, but when the bacilli could be recovered from the urine and 
autogenous vaccines given every 5 to 7 days, the results have been 
brilliant. The author does not attempt to explain these results 
of his clinical experience. 

One to two drams of bismuth subnitrate, followed in 30 minutes 
to one hour with 5 grains each of methylene and hexamethylenamin 
in salol coated capsules every 6 hours for an adult has given good 
results. 

The tormina and meteorism some cases complain of are best re- 
lieved by salol grains 5, hyocyamus grain %, camphor grain %, 
every four to six hours, and the application of heat over the ab- 
domen. 

AMEBIC DYSENTERY 

Synonyms. — Amebic colitis, amebic enteritis, amebiasis. 

Dysentery in this form is both epidemic and endemic in the 
tropical countries, especially India, Africa, and the Philippine 
Islands. In the United States sporadic cases are met frequently. 
Osier says that his cases in the Johns Hopkins Hospital were al- 
most exclusively amebic. It is very rare, indeed, that the author 
is called upon to treat a case of the severe acute or chronic type 
in which he is unable to make a positive diagnosis of amebic infec- 
tion by means of the microscope. 

This is the prevalent type of the grave, chronic, and relapsing 
cases of dysentery in this country, and many of the supposed 
diphtheritic dysenteries are of this origin. The microscope only, 
however, can verify or refute this opinion. 



DYSENTERY 



263 



Many cases of amebiasis have been diagnosed by the author 
when no history of dysentery or even diarrhea was obtained. 
He has also operated on two cases of amebic liver abscess, when 
the most careful inquiry failed to reveal a past or present history 
of the symptom dysentery or diarrhea. 

Etiology. — This form of dysentery is caused by the Entamoeba 
histolytica or the Amoeba dysenterioe (Fig. 174). (Councilman and 
Lafl eur. ) 




Fig. 174. — Amoeba histolytica (Schaud). A, young specimen; B, an older specimen 
crammed with ingested blood-corpuscles; C, D, K, three figures of a living ameba, which 
contains a nucleus and three blood-corpuscles, to show the change of form and the ecto- 
plasmic pseudopodia; n, nucleus; b, c, blood-corpuscles. — After Jurgens, from Albutt's 
System of Medicine. 



It is a type of protozoon, unicellular, and motile, several times 
the size of a red blood-corpuscle. In structure the organisms 
have an outer colorless zone, called the ectosarc or hyaloplasm, 
and an inner granular zone, the endosarc or emdoplasm. Its 
nucleus is eccentrically situated, and one or more vacuoles are 
present. This parasite is phagocytic in character, and may be 
seen to contain red blood-cells, bacilli, vacuoles, and other par- 
ticles. It is easily mistaken for a large epithelial cell, or Para- 
mecium, when not in motion. It is ten to fifty microns in size. 
The Amoeba histolytica multiplies by segmentation, the nucleus and 



264 



DISEASES OF THE RECTUM 



endoplasm dividing in such manner as to form several embryo-cells 
for the corresponding number of new cells. The old cell either dies 
or enters into the encysted state. After an uncertain period the 
cell-wall bursts, and liberates the new cells. The mother-cell, con- 
taining the daughter-cell, may remain encysted for an indefinite 
time. In this state it is much smaller than the ameboid form, and 
is non-pathogenic. 



V*~V-r» 






Fig. 175. — Amoeba coli mitis. A and B, living amebas, showing changes of form and 
vacuolation in the protoplasm; C, D, E, amebse, showing different conditions of the nucleus 
(n) ; F, a specimen with two nuclei, preparing for fission; G, a specimen with eight nuclei; 
preparing for multiple fission ; H, an encysted ameba containing eight nuclei ; I, a cyst 
from which young amebse (al) are escaping; J, K, young amebse, free. — After Casagrandi 
and Barbagalli, from Albutt's System of Medicine. 



There are two well-recognized species of amebse, the kind above 
described, and the Amoeba coli mitis (Fig. 175), which is occa- 
sionally found in healthy persons. This organism is also found in 
Other bowel affections. It is non-phagocytic, twelve to thirty-six 



DYSENTERY 265 

microns in size. Propagation is by gemmation or budding; a portion 
of the cell body being thrown out and then broken off, forming a 
new individual. 2 

All authorities now agree that the bacteria of symbiosis, and 
other associated micro-organisms, have much to do with the path- 
ogenicity of the amebse. 3 

I have observed with much interest certain of these symbiotic 
bodies, as also rod-shaped bacilli contained in the ameba in a class 
of cases to be referred to later. 

The ameba is not the only pathogenic organism to be con- 
sidered, therefore, during an attack of amebic colitis, for the colon 
bacillus is known to produce many of the pathological conditions 
in these cases ; so, this and other bacillary infections may at any 
time supersede in importance and virulency amebic infection; there- 
fore this fact and possible complication must at all times be kept in 
mind, and in this emergency met with proper treatment and diet. 

I have noted that the cases presenting themselves during the 
summer or autumn usually show the more active and phagocytic 
ameba?, or, more properly speaking, in those cases in which I 
have found the more active and phagocytic amebae, I have also 
found the greater virulence. In making microscopic examinations 
of most cases, the parasites are either very inactive or cease motility 
quickly, rendering necessary at times two or three examinations 
to make a positive diagnosis or, necessitate staining ; in which latter 
event the following technic which is practiced by the author is most 
satisfactory. 

Schaudinn's sublimate alcohol solution two parts, and one part 
absolute alcohol are mixed in a Petri's dish. Make a thin smear 
of fresh specimen on a slide and immerse in the above at once 
without drying, for 5 minutes, then harden in 80 per cent alcohol 
for 10 minutes, then wash in distilled water, stain with Hastings 
stain or other stain which may be preferred, 5 to 20 minutes, wash, 



2 After close observation, covering a great number of cases, the author has become con- 
vinced that there exists a pathogenic ameba which does not correspond exactly with the 
description above given of the Amoeba histolytica. 

This ameba is smaller, the hyaloplasm is not so distinct, though its lighter zone is dis- 
cernible, and this hyaloplasm or ectosarc can be seen forming pseudopodia. This ameba is 
both granular and phagocytic, and is often observed very active, hence, in the author's 
opinion, this ameba is likewise pathogenic. 

3 The Balantidium (Paramcecium) coli must be reckoned with as being responsible in 
part or wholly for some cases of colitis, and this parasite is always considered responsible 
for a part of the pathological conditions, when observed associated with the amebse. 



266 DISEASES OF THE RECTUM 

and dry by blotting;, and mount. Examine with high power, oil 
immersion, in strong light. 

By this method the cell nucleus, nuclear membrane, nucleolus, 
chromatin distribution, segmentation and other morphological char- 
acteristics of the different stages of the cell life may be studied. If 
the ameba is observed in the reproductive stages, the nucleus will 
be seen dividing into four segments, and finally into four young 
ameba?, which differentiates this from the ameba coli mitis; which 
latter contains eight nuclei. 

The ameba? are introduced into the intestinal tract through the 
mouth and stomach, but the acid gastric juices prevent their 
propagation. They pass on into the colon to gain lodgment at 
favorite points, namely, the ileocecal A r alve, hepatic and splenic 
flexures, and especially upon the plicce transversalis recti. In 
most cases the inflammation begins first in the rectum and ex- 
tends upward by continuity. 

The author has endeavored to explain the periods of exacer- 
bation and amelioration of symptoms, in the following ways: 

First. — The Entamoeba histolytica is especially fond of feed- 
ing on juicy subepithelial structures, and in a given case, this 
particular crop or generation, within the plentiful surroundings, 
may become indolent and easily satisfied, and also less active 
in the process of sporulation. 

Second. — The parasite may be in a state of encystation, dur- 
ing which period the amebae remain dormant or non-pathogenic 
until finally a different generation produces a more active and 
phagocytic type. 

Third. — Because of the presence of a greater or less number 
of bacteria of symbiosis, which, in the light of observation of 
most authorities, seem essential to the activity and virulency of 
the amebae. 

A further study of the problems of immunity may in the future 
yield information which will be of paramount importance in amebic 
dysentery, in reference to both the ameba and the symbiotic bac- 
teria. 

This disease is most often contracted through drinking water, 
raw vegetables, and fruits. 

Flies and other insects are possible means of transmission. 



DYSENTERY 267 

It can also be developed through contact, as from the use 
of syringe tips which had been used in treating an amebic case 
and not sterilized. 

When making a microscopical examination of the feces for amebas, 
the following technic will be helpful to the inexperienced mi- 
croscopist : 

Warm the slide slightly. Secure a small bit of the mucus from 
the stool and place upon the slide. Cover with a cover-glass quickly, 
and press it gently until the material is thinly distributed. Ex- 
amine at once with the one-sixth or the oil-immersion objective. This 
should be done as rapidly as possible, since the amebse retain 
motility for only a short time in temperatures much lower than 
body heat. If now they cannot be found, apply warmth by holding 
an electric-light bulb to one side of the stage. They may then be 
seen. Never be positive that the amebae are not present though 
not found. They may be in a state of encystation in the tissues, 
and only after an acute exacerbation of the disease, will they be 
found. 

A still better plan, and the only accurate way, is to examine 
the scrapings of the ulcerated mucous membrane. This method 
should always be practiced, when possible, after a saline catharsis. 

The most important of the associated organisms are the Strep- 
tococcus, Staphylococcus, Bacillus coll communis, Trichomonas in- 
testinalis, Paramecium, Cercomonas intestinalis, Lambia intestinalis, 
Bacillus pyocyaneus, and others. 

Pathology. — Pathological lesions are almost always confined to 
the rectum and colon, but occasionally the ileum may become in- 
volved. 

Appendicitis is quite common. 

The mucosa appears red and congested, and covered with mu- 
cus, usually tinged with blood. 

The infiltration and edema now invade the submucosa, necrosis 
of the overlying mucous membrane takes place, and the amebic 
ulcer is formed. This necrosed area may be oval or irregular in 
shape and appears to project over the level of the mucosa. 

The amebae gain access into the submucosa through the in- 
terglandular spaces and carry with them the associated organisms. 
Here they set up an active inflammation, and produce ecchymosis 



268 



DISEASES OF THE RECTUM 



and swelling of the glands. The number of the amebaa in the 
submucosa is great, since they prefer this juicy subepithelial tis- 
sue, no doubt because they find food more easily. When they get 




Fig. 176. — Slough of mucous membrane, 28 inches in length, from a fatal case of dysentery. 
Photograph of specimen from one of Jelks' cases. 



into the submucosa, their presence excites a reactive inflammation 
at once. 

It is important to note here that the bacteria of symbiosis play 
a very important part in the inflammation just described. Nec- 
rosis now takes place in the inflammatory area, and sloughing 



DYSENTERY 



269 



follows. Iii grave and fatal cases this undermining process, so to 
speak, may become so extensive, and the congestion so great, that 
large areas will necrose and slough. The author has preserved one 
specimen of this character twenty-eight inches in length (Fig. 176). 

The muscular coat of the bowel offers greater resistance to 
the amebae, so that they seldom invade it. Occasionally, how- 
ever, this undermining process will extend into the intermus- 
cular tissue, and produce the same results as before described. 

In this way the larger and deeper ulcers form (Fig. 177). 




Fig. 177.- — Edge of intestinal ulcer. (Toluidin-blue and eosin. Beck 1 inch. Oc. 3.) — 
Courtesy of Dr. H. F. Harris, Atlanta, Ga. 

a. Mucous coat which projects over ulcer at f. 

b. Submucosa. 

c. Circular layer or muscle-fibers. 

d. Tissues of mesocolon. 

e. Amebae in dilated lymph-spaces. 



The involvement of the rectum in one case was so extensive 
that the new scar-tissue produced an almost complete stenosis. 
Higher up the ulcerations usually cover a smaller area. A sharp- 
edged, clean-cut ulcer results, or a simple erosion only may be 
observed. This ulcer may involve the greater portion of the 
thickness of the wall of the bowel, but the undermining is not 
so extensive and the thickening that results lower down is not 
so marked here. One post mortem revealed nine distinct perfora- 



270 



DISEASES OF THE RECTUM 



tions in the splenic flexure, which produced sudden death when 
the loose attachment of the omentum was broken by gaseous over- 
distention. 

The author wishes also to call attention to certain spots and 
lines which he considers almost diagnostic when present. By 
careful examinations with the proctoscope small red papular spots 
may be seen dotted about among the already well-defined ulcers. 
Perhaps on the following day the red spots will show a little 




178. — Dysenteric ulceration on the valves of Houston. — After Tuttle. 



white or yellow point of necrosis in the center. Upon the next 
examination an ulcer will be seen to have taken its place. 

In another instance a few circmate or ringworm-like lines in 
the mucosa, a picture which is not observed in other forms of 
intestinal infection, will be seen. These lines or ulcers are chiefly 
submucous, but sooner or later break into the undermined ulcer, 
and may then assume any shape. New lines will form, however, 
to tell the story (Fig. 178). 

The author has also observed small openings at points along 



DYSENTERY 271 

the courses of these circinate lines leading to extensive submucous 
ulcers. At other times the intestinal mucosa presents only a few 
circinate lines overlying the subepithelial ulcers, while the re- 
maining mucosa presents a reel granular appearance. 

In a few cases (unmistakably amebic) the disease appeared 
to be only a hypertrophic proctitis, or a proctosigmoiditis, and 
in others the mucosa appeared puffy or edematous. 

It is very probable in my opinion that some of these condi- 
tions were concomitant and due to associated conditions, espe- 
cially collateral infections. This important fact must not be lost 
sight of: the pathological conditions produced by the ameba, as 
also the amebse themselves, are mostly submucous ; while the col- 
lateral infections and the conditions produced by them are, as a 
rule, superficial. 

Amebse have been found free in the peritoneal cavity, and in 
other parts of the body, especially the liver. Here, when unas- 
sociated with collateral organisms, the parasites are non-pyogenic. 
A true amebic, unassociated infection in the liver would mean 
simply that; and not an abscess cavity filled with the most of- 
fensive pus, as is so often found. Perhaps, in almost all cases, 
amebaa have been conveyed into the liver, and but for the fact 
that they were unassociated with pyogenic organisms, abscesses 
would surely follow. Hepatic abscess complicates probably twenty 
per cent of all chronic amebic infections ; however, exact statistics 
cannot be obtained. 

Councilman found this complication in six out of eight au- 
topsies. 

Strong and Musgrave found it in fourteen out of ninety-seven 
autopsies. 

Out of a series of twenty-five cases treated by the author in 
1908, four were complicated by hepatic infections. In two of 
these cases the diagnoses Avere verified by operations. In one 
a large abscess of the right lobe was found, and in the other 
the right lobe was inflamed and firmly adherent to the omentum 
and hepatic flexure of the colon. A cholecystitis was also pres- 
ent, and required drainage for six weeks. 

The infections may be carried into the liver in two ways: 



272 DISEASES OF THE RECTUM 

First, and most probable, through the portal vein, which has 
often been found infected (Plate IV). 

Second, by transmission through the intestinal wall. 

Craig claims that the kidneys often present the lesions of acute 
parenchymatous nephritis. 

Symptoms. — In the more virulent or malignant cases the onset 
is usually sudden, and may or may not be ushered in with a 
rigor. The attack is preceded by a period of malaise, often ac- 
companied by constipation. An attack of acute indigestion often 
precedes this form of dysentery. The patient may have six to 
forty bowel movements during the first twenty-four hours, usually 
sero-sanguineous in character. Prostration is early. By the second 
or third day considerable blood and pus begin to appear, the 
latter being very offensive in odor. Prostration increases with the 
further absorption of toxins. Temperature usually rises to 102 
to 103 degrees F., and is of the irregular remittent type. Delirium 
may be pronounced. General abdominal pain and tenesmus with 
tympanites and tormina are prominent. The facies abdominalis 
denotes suffering and anxiety. The nose is pinched, and the upper 
lip is retracted; and the condition now is a grave one. The thighs 
are flexed upon the abdomen and legs upon the thighs in such 
manner as to relieve pressure upon the abdominal viscera. Con- 
siderable tenesmus precedes and accompanies all bowel movements 
and may follow for several minutes, though as a rule a greater 
or less relief follows the passage of only a small amount of bloody 
mucus. Later the more offensive discharges, containing greater 
quantities of mucus, pus, and blood, with perhaps mucofibrinous 
casts, or mucous membrane sloughs, indicate necrosis. 

The above symptoms are soon followed by delirium, subnor- 
mal temperature, rapid, feeble pulse, clammy perspiration, glazed 
skin, collapse, and death. If, after the sloughs are passed, the 
patient survives the sepsis and toxemia, and healing of the ul- 
cers follows, the process is a slow one. These ulcers are finally 
filled with granulation tissue and fibrinous material, which con- 
tract, causing more or less stenosis. The symptoms of sepsis and 
toxemia from the absorption of necrotic material and toxins very 
gradually diminish until the patient is able to resume his regular 
occupation. 




PIRATE IV. 



Section of intestine just below ulceration. (Toluidin-blue and eosin. Beck, z /[, Oc. 3.) 
In tipper portion of the field a large vein is seen; the wall of the vessel which is nearest 
the ulceration is being infiltrated with small cells, and aniebse are breaking down; both 
red and white cells and amebic are seen within the lumen of the vessel. In the lower por- 
tion of the field many amebae are seen — some in the tissues, and others in the lymph-spaces 
and lymph-channel. — Courtesy of H. F. Harris, Atlanta, Ga. 



DYSENTERY 273 

The following case reports will be helpful : 

Case 1. — Name, Dr. ; age, 36 yeiars; race, white; occupation, physician; 

family history, negative ; previous state of health, good, until six months previous, 
during which time he suffered a rapid decline. Symptoms: Lost thirty or forty 
pounds in weight; complained of slight colicky pains over course of colon; trou- 
bled with loose fermentative diarrhea; inactive liver; coated tongue; temperature 
99 2/5° F.; pulse, 60; skin, dry and muddy; slight tenderness on pressure over 
cecum, hepatic and sigmoid flexures; pronounced melancholia, insomnia, and 
malaise were present. Had not noticed passages of mucus from bowel but spoke 
of a very offensive odor. Proctoscopy revealed a considerable quantity of san- 
guino -purulent mucus in the rectum, and the rectal mucosa was covered with same, 
mixed with some light-brown fecal material. Small circinate lines and punctate 
ulcers were seen on the rectal walls and valves of Houston. A mild granular 
proctosigmoiditis was noted. Microscopic examination revealed Entamoeba histo- 
lytica, Trichomonas intestinalis, Paramcecia, and others. 

Diagnosis: amebic dysentery. 

Case 2. — Name, Dr. ; age, 53 years; race, white; occupation, physician; 

family history, negative; previous health, good, until 23 years of age since which 
time he has never been well. Symptoms; At the age of 23 suffered a very severe 
attack of dysentery, and for a long time, hope of recovery was despaired of. Later 
a change of climate seemed to contribute to his slow but apparent recovery. 
After returning home suffered a relapse. Since that time has suffered abate- 
ment and acceleration of symptoms ; alternating attacks of diarrhea and consti- 
pation; suffering now from profound melancholia and insomnia with suicidal in- 
clinations. Temperature, subnormal; pulse, 65; tongue, dry and coated heavily, 
round and thick ; skin, inactive and muddy ; liver, enlarged, extending three inches 
below costal border and tender, probably the seat of a large abscess. Pain on 
pressure over entire course of colon, especially over cecum and sigmoid flexures. 
Furunculosis (staphylococcic) over entire body; atonia gastrica with dilatation; 
kidneys, normal. 

Proctoscopy: rectal walls very much thickened, scarred, and stenosed, this last 
condition observed at rectosigmoids! juncture also ; red granular hypertrophic rec- 
tosigmoiditis. The characteristic ulcers, previously referred to, were found beneath 
a coating of offensive blood-tinged mucus, which was mixed with pus. Micro- 
scopic examination revealed large active phagocytic Amoeba histolytica, colon ba- 
cilli, Trichomonas intestinalis, Cercomonas intestinalis, and other symbiotic bodies 
in great numbers. The blood examination, made by Dr. Krauss in this case, shows 
the following: 3,940,000 red cells, 75 per cent hemoglobin, 13,700 white cells, of 
which 74 per cent were polynuclears and 3.3 per cent eosinophils. The opsonic index 
failed. The bacteria isolated from the pustules were Staphylococcus albus and 
a single colony of aureus. I regard the blood condition to be one of secondary 
anemia with mild coccus infection, and the moderate eosinophilia is probably due 
to the intestinal condition. 

The furuncles were healing nicely when I last saw the patient, and he ex- 
pressed himself as feeling greatly improved. 

Diagnosis: amebic dysentery. 



274 DISEASES OF THE RECTUM 

The author looks with suspicion upon any case of dysentery 
or diarrhea, recurring or relapsing*, which has failed to respond 
promptly to treatment. 

Dysentery and diarrhea are not essential symptoms of the exist- 
ence of amebiasis, though this is contrary to the generally accepted 
theory. In many cases the patient will complain of recurrent diar- 
rhea which has existed for months or years. These attacks are 
accompanied by passages of mucus, usually considerable in quantity, 
and occasionally stained with blood. The patient complains of 
almost constant pain or discomfort in the left iliac fossa, and when 
the lower rectum is the seat of considerable ulceration, pain at 
the end of the spine and in the rectum is felt. This symptom is 
momentarily relieved by evacuations. 

A case from the Mississippi Delta, reported by me to the American 
Proctologic Society, had most violent symptoms from the onset. 
On the fifth day a large slough of mucous membrane (Fig. 176) 
was passed en masse. Thirty-six hours later the patient died. 

Most of the chronic cases will give a history of having lost 
much weight, perhaps twenty to fifty pounds. Many have symp- 
toms of interest to the stomach specialist, and to the neurolo- 
gist. 

Complications and Sequelae. — These are very numerous indeed. 

Of 1537 cases of diarrhea in Egypt, only 406 were uncomplicated. 

Hepatic abscesses were found in six out of eight autopsies by 
Councilman. In four of these they were multiple. 

Strong and Musgrave found hepatic abscesses in 14 out of 97 
cases. The author, as previously stated, found liver infections in 
four out of twenty-five cases. 

The vermiform appendix has been found to be involved in fully 
ten per cent of chronic cases by the author. 

Among the other complications most frequently occurring are : 
perforations, extensive sloughs, hemorrhages, fibrosis of the valves 
of Houston, rectal stenosis, adenomata recti, cholecystitis and 
jaundice, perirectal abscess, hemorrhoids, fistula, pneumonia, pul- 
monary abscess, pleurisy, bronchitis, nephritis, portal thrombosis, 
cerebral and meningeal emboli, gastritis, atonia gastrica, melan- 
cholia, which is often profound, and in many of my cases more 



DYSENTERY 



275 



or less extensive skin lesions and nervous symptoms have been 
observed. More especially have these complications been seen in 
chronic cases, but these are considered of sufficient importance to 
deserve the following special mention: 

Dr. John L. Jelks' report: 

Skin and nervous manifestations and complications referable to blood contami- 




Fig. 179. — Photograph of case, Mr. A. R. C. 

nation and poisoning of the central nervous system, to which special allusion 
seems apropos. 

For the past 13 years the author has interested himself in the unmistakable 
relationship between amebiasis and various skin and nervous manifestations of 
varying character and severity, and was the first writer to allude to these symp- 
toms and complications in several monographs written during these several years. 



276 DISEASES OF THE RECTUM 

Many of these manifestations arc so vague as to escape other than the scrutiniz- 
ing eye, and varying thus from this mild coccus infection or toxic manifestation 
above referred to, he lias observed the most distressing urticarial, erythematous, 
and desquamative dermatitis, and in the first part of April, 1910, the author pre- 
sented before the Tennessee State Society a patient who was a well-defined pella- 
grin and who had suffered amebic infection for three years. 

The object, in referring to these manifestations, is to show the grave complica- 
tions of this character, which may associate themselves with amebic ulceration and 
collateral infections. 

Case Keport : Mr. A. R. C, age 40, American ; occupation, lumberman. Father 
living; health, good; age 71. Mother died of tuberculosis at the age of 36. 

About twenty years ago, the patient became overheated and began having in- 
digestion, diarrhea, and dysentery. Fifteen years ago, suffered a very severe dys- 
enteric attack. Again five years ago, patient began passing large quantities of 
mucus, which at times was mixed with blood and pus. 

His symptoms grew progressively worse, and on December 8, 1911, he was 
brought to me for examination. His emaciation was extreme and general condi- 
tion bad. His blood picture denoted anemia and toxemia. 

Proctoscopy: The rectum and sigmoid were eroded and contained offensive 
mucus, blood, and pus. The typical amebic ulcers were curetted, and the material 
revealed large numbers of Amoeba histolytica and symbiotic bodies. 

The amebae contained blood-corpuscles and blunt, rod-shaped, nonmotile bacilli, 
distributed without order in great numbers. Colonic irrigations were begun and 
patient's diet restricted to albumin and buttermilk, but the patient's condition 
grew steadily worse. 

On December 21, 1911, appendico-cecostomy was performed, and irrigations 
were begun the following day. Improvement was noticeable, and a more liberal 
diet permitted, which was followed by a relapse and profound toxemia. In two 
days marked improvement again was noted, the result of persistent irrigations with 
large quantities of salt solution and restrictions of diet. The appended illustra- 
tion was taken at this time (Fig. 179). 

He no longer passes mucus or blood; he is up from four to six hours each day. 

The case is one of amebiasis associated with the series of symptoms-complex, 
known as pellagra. 

. The prognosis must appear grave indeed; yet, great improvement has resulted 
from the treatment. 

Dr. Marcus Haase's report February 22, 1912: 

In regard to the patient I saw with you, Mr. A. R. C, at the City Hospital on 
December 10, 1911, I find that I made the following record: There was an 
erythemato-squamous condition on the backs of the hands, elbows, nose, the left 
side of the neck, and about the ankles. All of these lesions were sharply defined, 
in no instance gradually extending into the normal skin, and were all of a dis- 
tinctly pellagrous character, and I was at that time quite satisfied that the disease 
from which he was suffering was unquestionably pellagra. 

I saw this patient again on February 18, 1912, and at that time the lesions 
had entirely disappeared. The skin, while atrophic, was not as markedly so as I 



DYSENTERY 277 

should have expected in a case of this severity. While we might expect all acute 
lesions to disappear in this length of time, I should expect to find an atrophic 
condition more marked than I found in this case. 

Dr. W. C Sommerville 's report: 

Mr. A. R. C, male, age 40 years. Five or six years ago began with weakness, 
especially in legs, and indigestion, a sensation of heaviness in gastric region. Has 
been unable to do a whole day's work during this period. Two years ago weak- 
ness of legs was more decided and has progressively increased since. Vertigo 
for past two or three years. Diplopia for past eighteen months. In September, 
1911, had an eruption on backs of both hands, which had the appearance of sun- 
burn. Says he has been sunburned several times. Does not know how long his 
limbs have been atrophied. 

Mental condition: Dull, memory bad, and rather irritable and depressed, an- 
swers slowly, and is unable to recall his symptoms with airy degree of accuracy. 
Patient presents a condition of a very decided general emaciation, but in addition, 
there is more or less general muscular atrophy, especially marked in the small 
muscles of both hands, but involving to some extent ^almost the entire musculature. 
Pupils dilated but equal, and react to light and by accommodation. External 
ocular muscles negative. 

Diplopia arid nystagmus present. Sensory branch of fifth nerve negative; some 
weakness and atrophy of muscles, supplied by motor branch. Slight weakness of 
facial muscles, hearing fairly good, and air conduction greater than bone con- 
duction. No difficulty in swallowing. Movements of tongue weak, and tongue 
slightly atrophied. 

There is decided loss of power in all movements of the four extremities, 
especially marked in small muscles of both hands, which are decidedly atrophic. 
There is no paresthesia, and no sensory disturbances of any kind, except tingling 
and numbness over anterior surfaces of both thighs, which show a hyperesthesia, 
and hypalgesia; slight tingling and numbness of hands and feet. Has poor con- 
trol over sphincter of bladder. Slight incoordination manifested in making nose- 
finger test. 

No wrist-jerk was obtained, either right or left. Both elbow-jerks were brisk 
and equal. Both knee-jerks were brisk and equal. The ankle-jerks present and 
equal. The plantar reflexes were extensor, both right and left. External malleolar 
reflex not obtained. Abdominal reflexes present. 

The symptoms, which this patient presents, indicate extensive degenerative 
changes in the cells of anterior horns and the motor nuclei; of some of the cranial 
nerves; and degeneration of the crossed pyramidal tracts; and beginning de- 
generation of the posterior columns of the cord. 

Statistics from all sources show that perhaps twenty per cent 
of all cases are complicated by hepatic infection. The right lobe 
is most often involved. The author believes this complication 
will appear less frequently in the future, owing- to better diag- 
nostic facilities, care, and treatment by the internist. 

Perforations may occur along the course of the colon at any point 



278 DISEASES OF THE RECTUM 

between the rectum and appendix. Perforative appendicitis lias 
been noted. 

Perforations occurred in 85 out of 580 cases selected by Beranger 
and Feraud. 

Stenoses have been observed in a large per cent of chronic cases 
usually in the rectum and sigmoid. When fibrosis of the rectal 
valves is observed, it is a grave obstacle to the complete cure, owing 
to interference with drainage and local treatment. 

Hemorrhoids, though frequently noted, are not serious complica- 
tions as a rule. 

The other complications mentioned above should be borne in 
mind and treated when they occur. 

Diagnosis. — This is rendered easy by means of the microscope, 
all doubt being removed by finding the Entamoeba histolytica in the 
stools, or in the material curetted from the ulcers in the rectum 
and sigmoid. 

Prognosis. — The prognosis in amebic dysentery is likewise much 
graver than in the acute catarrhal form. It may be said to depend 
upon several things: 

1. The previous state of health of the patient. 

2. The hygienic condition of the patient's surroundings. 

3. The efficiency of the treatment employed. 

In the United States the total number of deaths from all forms of 
dysentery in 1850 was 20,556, a per cent of 6.32 of the total mor- 
tality. 

In 1880, out of 756,893 deaths, 10,825 were from dysentery. 

Treatment. — The treatment of dysentery will be discussed under 
the heads: (a) Prophylactic, (b) Dietetic, (c) Remedial and Opera- 
tive. 

Prophylactic. — Strict attention should at all times be given to 
the hygienic condition of surroundings. Remove and avoid as far 
as possible the causes of dysentery. Cases should be isolated when 
it is possible to do so. All excreta should be carefully disinfected 
and deposited where the water supply will not be contaminated. 
The country practitioner, living where there is no sewerage system, 
should never neglect to caution those attending the patient to de- 
posit the excreta in a hole dug for the purpose as far removed from 



DYSENTERY 279 

the water source and garden as possible, after first disinfecting 
thoroughly. 

If a person, knowing the danger, were to deposit the excreta of 
a dysenteric patient in a garden, it would be inexcusable. The 
author has, however, seen this done by some who had never sus- 
pected danger in so doing. In the country, and in small towns, 
without sewerage, small closets are usually found in or near the 
gardens, and are often made sources of fertilizing material for the 
growth of vegetables. It is the duty of the physician to educate 
his patients in regard to all dangers resulting from such gross un- 
sanitary practices. Wells and cisterns are contaminated much 
more often than the average layman suspects. When the source 
of the drinking supply is at all questionable, the Avater should be 
boiled before drinking. 

Overcrowding and poor ventilation should be prevented. The 
care of the room occupied by the patient is important. Unneces- 
sary furniture, such as curtains, rugs, carpets, etc., should be re- 
moved. Disinfectants should be used at regular intervals. Linen 
should be changed daily. Bedpans, commodes, drinking cups, etc., 
should be disinfected thoroughly. 

Diet. — Diet is as important as an}^ other matter in the treatment 
of dysentery. During this period of acute intestinal symptoms it 
should consist of buttermilk, whey, egg whites, barley water, and 
perhaps one of the standard malted milk foods for infants. 

In all cases select a diet which is digested as far as possible in 
the stomach, and which has little waste. Food is best given at in- 
tervals of one to two hours in acute cases. Plain sweet milk may 
be diluted with barley or rice water, lime water or Vichy, if im- 
perfectly digested. 

In the bacillary form of dysentery and in those cases in which 
this form of infection is suspected of much part in the inflammatory 
process, milk in any form should be eliminated for a safe period of 
time, and the diet restricted to albumin, whey, barley water, and 
abundant sterile water. In these cases animal broths are very liable 
to produce a rich media for the bacillary growth. 

While fruits in general are interdicted, the juices of oranges, 
lemons, and pineapples have not given particular disturbance in 



280 DISEASES OF THE RECTUM 

most cases in which they have been used, especially as palatable 
vehicles for albumins. 

During convalescence in all forms of dysentery and for chronic 
cases, the author prefers buttermilk, whey, and eggs. In some 
cases tender portions of turnip tops, mustard, spinach, and aspar- 
agus tips have been given, and were relished by the patient. It is 
however, questionable as to the advisability of giving the patient 
much vegetable diet. 

In cases of amebic dysentery the author is especially partial to a 
diet of milk and egg whites. The eggs may at times be prescribed 
in large quantities, from eight to fifteen per day. They can be 
ordered raw, mixed with milk, or in the form of fruit-albumin. The 
last is made by stirring the white of one egg into a glass half full of 
crushed ice, then flavor with orange or other fruit juice. Diffusible 
stimulants, such as champagne, sherry wine, or whiskey, may also 
be added to the egg mixture when cardiac weakness and adynamia 
are present. 

The albumin may also be mixed with sweet milk, or sweet milk 
with lime water in the form of a milk-shake, to which may be added 
the alcoholic stimulants, if no contraindications exist. 

Buttermilk is an especially favorite diet. Its acid properties make 
it desirable. 

The articles of diet which are contraindicated are all dishes 
highly seasoned with pepper, cinnamon, nutmeg, etc. Vegetables, 
especially the raw varieties, pork, salt meats, veal and fish, sac- 
charine foods, fried foods, nuts, oatmeal, and fruits, other than those 
mentioned, should also be interdicted. 

Remedial. — The medicinal treatment of dysentery is a most in- 
teresting subject. A great number of so-called specifics, and much- 
praised remedies, have been handed down to us, but most of them 
have proved so unsatisfactory that it is no surprise that most of 
the present-day suggestions are greeted with a certain amount of 
skepticism or personal prejudice. The systemic treatment as a cure 
for dysentery is erroneous. It is a local disease and therefore re- 
quires local treatment. This is certainly true with reference to 
immediate pathology, but other remote pathological conditions may 
require constitutional treatment. 

The ameba is a very Ioav form of organic life and is very easily 



DYSENTERY 281 

killed or rendered inert. The fact remains, however, that the par- 
asites are embedded in the tissues in such vast numbers as to make 
their destruction difficult. Certainly any chemical which is given 
by mouth, after passing through the stomach and small intestines, 
can possess little parasitic effect when it reaches the lower colon, 
sigmoid flexure, and rectum. Therefore, our chief reliance must be 
placed in local applications, which are used for the following pur- 
poses: namely, that of washing away the pus, mucus, and debris, 
and at the same time the amebae and other pathogenic organisms, 
also that of antisepticizing the bowel contents and walls, that the 
further growth and development of the pathogenic organisms will 
be inhibited. 

It is also important to remember that the remedies selected should 
be those which will destroy the greatest number of organisms be- 
neath the lining membrane of the bowel without destruction to the 
tissues themselves. 

In the earlier stages of acute dysentery the patient should be put 
in bed, and absolute quiet enjoined. Chilling draughts of air are 
to be cautiously avoided, since they are apt to increase the conges- 
tion of blood toward the internal viscera. Bathing the patient with 
warm water, vinegar, or alcohol will often give great comfort by 
relieving the burning sensation in the skin. The perianal region 
should be sponged frequently with an antiseptic wash, such as a 
mild boric acid and formalin solution, and dusted with some mild 
antiseptic powder, as equal parts of boracic acid and aristol. An 
ointment of similar composition may be used instead. Applications 
of heat or cold to the anal region will often relieve the burning and 
tenesmus in the lower rectum. The hot hip-baths also have been 
very helpful in relieving this condition. 

In the more severe cases the constant application of ice bags over 
the left iliac region gives comfort. Hot fomentations are sometimes 
to be preferred, but in the majority of cases, the ice bag is better. 

The severe griping and tormina are relieved quite readily by hot 
turpentine stupes or by large flaxseed-meal poultices. These may 
be used just as frequently and for as long a period as needed. 

Laxatives. — Occasionally absolute rest and strict diet are all that 
are needed to relieve the patient, but it is in most cases best to ad- 



282 DISEASES OF THE RECTUM 

minister some mild laxative to remove the contents of the bowel, 
which acts as both a mechanical and chemical irritant. 

Castor-oil and magnesium sulphate, to the latter of which may be 
added dilute sulphuric acid, are the most popular remedies for this 
purpose. The salines, by their hydragogic action, deplete the in- 
flamed mucosa and wash away many of the infecting micro-organ- 
isms. It must be remembered, however, that all purgatives act as 
irritants to the intestinal mucous membrane in a greater or less 
degree, and their use must be guarded with judgment. In some 
cases they would be harmful. If there has been much diarrhea and 
the stools are copious and thin, purgatives are contraindicated. 

When to repeat a purgative is another question that should be 
considered with care. Often much harm is done in this way. 

Calomel, or calomel with ipecac, is often ordered in small doses 
for a dry, furred tongue, and inactive liver with foamy acrid dis- 
charges. Our aim in giving calomel is not only that of producing 
the antiseptic action of bile, but also, by depleting the liver, of re- 
lieving the portal congestion; and this, in turn, the congestion of the 
veins about the rectum. The severe griping pains and tenesmus, 
the diarrhea, and restless condition of the patient, when present, 
must be relieved, or the outcome will be rapidly adverse. Opium is 
the remedy, either in the form of Dover's powders, paregoric, lau- 
danum, or morphin. This last is no doubt the most popular form 
of the drug and is best used hypodermatically. The dose should be 
just large enough to keep the patient quiet and to relieve the suf- 
fering, but never sufficient to produce narcotism. 

It must not be forgotten that opium may do great harm in some 
instances. If nature is attempting to throw off the putrid contents 
of the bowel in large, liquid stools, we should not give opium, for 
in doing so we are interfering with her efforts to relieve the condi- 
tion. 

A large number of intestinal antiseptics have been given inter- 
nally for dysentery, the principal ones being calomel, lead acetate, 
zinc sulphocarbolate (in one-half to three-grain doses), salol, guai- 
acol carbonate, bichlorid of mercury (dose, grains %20 to %so), Si^ 
acetozone. These are all, however, given by the author with a feel- 
ing of uncertainty. 

Those cases which begin with symptoms of cholera morbus, with 



DYSENTERY 283 

nausea and vomiting, and subnormal temperature, call for hypo- 
dermic injections of morphin sulphate, gr. %, and atropin sulphate, 
gr. Ysoo- To control nausea, may be given carbolic acid and tincture 
of iodin, each one minim, well diluted, by mouth. This is followed 
by calomel, gr. .%-%, and salol, grs. 2 to 5, with just a sufficient 
amount of hot water to administer same. In many cases of nausea 
the ideal treatment is that of stomach lavage, using very hot water, 
to which is added oil of cloves one-half to one dram per quart and 
briskly agitated. 

In other cases cocain hydrochlorate (gr. %-%), or chloretone 
(grs. 5-15) may be given. Where there is much depression, warm 
enemata of normal salt solution may be given, or this may be given 
by hypodermoclysis. The effect is a dilution of the toxins and a 
reaction. A mustard plaster or hot turpentine stupe over the 
epigastrium is beneficial in these cases. If the temperature and 
pulse are not subnormal, the tormina, tenesmus, and burning can 
be allayed by enemata of cold water, the temperature of which 
should be regulated to suit the case. 

When there is marked irritability of the rectum, the following 
suppository should be inserted before injections are made : 

I)c Cocaine hyclrochloridi 
Extracti stramonii 
Extracti belladonna: aa gr, ss 
Olei theobromatis q. s. 
Misce et fiat suppositoria, No. 1. 
Sig. : Hold the suppository in the anal canal about one minute then press into 
the rectum with the index finger. 

Kartulis claims that he found ipecacuanha to have an almost 
specific influence upon dysentery. 

His method of administering this drug was to give a one-half 
grain injection of morphin hypodermatically and place a mustard 
plaster or turpentine stupe over the epigastrium. After half an 
hour twenty grains of pulv. ipecac were given, and this dose was 
repeated every half hour to one hour, until an ounce had been given. 

Another method of giving this drug: Put 2 to 8 grams (% to 2 
drams) in 500 grams (1 pint) of water and let stand two hours. 
This solution is filtered off and constitutes the first dose, or this is 
at times divided into two or more doses. According to Kartulis, 
this always produces emesis and diarrhea, but after a second or 



284 DISEASES OF THE RECTUM 

third infusion, which is made from the remaining portion of the 
powder with the same quantity of water, has been taken, the vomit- 
ing and purging become less frequent. 

If, after the third day's treatment with these infusions, the pa- 
tient has not improved, another series of infusions with a fresh sup- 
ply of ipecac should be given. 

The author has mentioned this treatment only to condemn it. It 
has been known to produce death, and does not cure the disease. 
According to some authors, there is no reason for dysentery exist- 
ing in the same world with ipecac and that this drug will even 
abolish an established abscess of the liver. Such is one of the curi- 
osities of the statistics found in a recent article by McDill. I have 
administered large doses of ipecac daily for a week, then found 
the living amebaa in the bowel scrapings as if undisturbed by the 
drug. In all cases it is a cardiac depressant and lowers the phys- 
ical resistance of the patient It is a violent intestinal irritant. 
The powdered drug has also been found impacted in fatal perfor- 
ating ulcers of the bowels. To my mind, therefore, its adminis- 
tration in this disease, by this method, is dangerous, adding insult 
to injury. 

Its alkaloid Emetine Hydrochloride has been given by the author 
in y 2 to 1 grain doses in perhaps two hundred cases, and Avith very 
certain and uniformly good results in so far as concerns the re- 
lief of symptoms and healing of the ulcers, yet, he has never cured 
a case of amebic infection by this treatment. They will and do 
have relapses, and recurrences of symptoms ; therefore, the author 
concludes the remedy is deceptive, and the cases are carriers of the 
infection. 

For the acute catarrhal type the elimination of irritating sub- 
stances and free exosmosis, obtainable by the administration of 
Epsom salts, and enjoined rest in bed, with abstinence from all but 
the blandest forms of diet, will often suffice. In these cases, how- 
ever, the injection of tepid Avater, containing to each quart, minims 
x to xx of formalin, and one tablespoonful of boric acid, may be 
necessary. This is often followed by the same quantity of cold 
water, or by the injection of 1 or 2 ounces of olive oil and one scruple 
of bismuth subnitrate. These injections can do no harm and are 



DYSENTERY 285 

surely destructive to the life and propagation and pathogenic prop- 
erties of the infecting agents. 

If the symptoms do not abate, and the patient does not obtain 
marked relief within the first few days from the use of the above- 
described treatments, pathologic conditions may be present which 
may require other forms of local treatment in the nature of topical 
applications. 

A subacute catarrhal condition may supervene in which an 
astringent and antiseptic treatment will be required to complete the 
cure. For this purpose may be used the injection of a tannic acid 
solution, one dram to a pint of water, followed by the introduction 
of a suppository containing: 

Iy Extracti belladonnas gr. ss 

Extracti stramonii gr. ss 

Thymolis iodidi gr. v. 

Olci theobromatis q. s. 

Misce et fiat suppositoria No. 1. 

Or the following ointment : 

IJ Extracti belladonnas gr. ss 

Extracti stramonii gr. ss 

Thymolis iodidi gr. v. 

Petrolati liquidi q. s. 
Misce et fiat unguentmn. 

If the disease assumes one of the more virulent types, and if the 
ulceration is extensive, still more radical measures should be sought 
in the high irrigation with the formalin-boric solutions. These, if 
possible, should be given through a recurrent tube (Fig. 180), since 
by this means only can a large quantity of the solution be used 
without distending the inflamed and ulcerated bowel to a painful or 
perhaps dangerous degree. 

Four to eight quarts of this solution are usually required for one 
irrigation. 

Some authorities are partial to the use of quinin solutions 
(1:5000 to 1:500) in cases of amebic infections. Among the advo- 
cates of this drug are Musgrave and Strong, and Osier. H. F. Har- 
ris, of Atlanta, says: "I used this treatment with great persistence 
in some of my earliest cases, but not in a single instance was there 
the slightest perceptible result. Injections of 1:100 to 1:300 watery 



286 



DISEASES OF THE RECTUM 



solution of bisulphate of quinin were somewhat beneficial in one 
or two instances." 

My own experience with these injections is in accord with that 
of Dr. Harris. 

Hanes, of Louisville, treats these amebic infections of the colon 
with kerosene oil ; the oil is poured into the colon while the patient 
is inverted. 

The use of formalin solutions in the strength of 1:500 to 1:1000 
has in the author's hands afforded the best results. 




Fig. 180. — The Jelks soft-rubber recurrent recto-colonic irrigating tube. — Courtesy of Dutro 
and Hewitt, Memphis, Tenn. 

My study of the effects of this chemical has extended over a period 
of 12 years. I have relied not only upon clinical results obtained, 
but also upon the microscopical observations in demonstrating the 
efficiency of formalin. After only one or two injections with these 
solutions, I have been unable to find any living organisms in the 
bowels for hours afterward. This, it was observed, was not the case 
when other solutions were used. 

Rapid healing of the ulcers was always noted while continuing 
the irrigations of the formalin in the above-mentioned strengths. 

To be certain of the effect of this drug, its use was discontinued 



DYSENTERY 287 

for the time being, and such irrigations as plain water (warm or 
iced), normal salt, and quinin solutions were substituted. In every 
instance the ulcers re-formed, and both amebas and bacteria of 
symbiosis were found again in the microscopical examinations. 
Upon returning, however, to the formalin irrigations, these micro- 
organisms disappeared, and the ulcers began the process of repair. 
Thus the author has concluded that this chemical, judiciously used, 
is really the most effective in the destruction of the amebse and as- 
sociated organisms, and most valuable in the treatment of dysen- 
tery. 



1^9 ^^» * N -\— // \ 1 
wk \ 

1 \ 


if 


i 



Fig. 181. — Exaggerated Sims' position, showing method of high irrigation of colon through 

Jelks' recurrent tube. 

During the past two years I have been giving iodin and thymol, 
internally, with gratifying results. The latter is especially valuable 
in that it destroj^s not only the amebas but other intestinal parasites. 
I find solutions of iodin and of thymol of especial value when used 
as colonic irrigations. This method appeals to me most when the 
solutions can be applied through the cecum. 

Seven grains of thymol dissolved in a pint of water, and filtered, 
give a solution whose strength is approximately 1:1000. A solution 
of this strength may safely be used in irrigating the colon through 
the cecostomy opening. This solution should be followed by a solu- 



288 



DISEASES OF THE RECTUM 



tion of magnesium sulphate or sterile water. Thymol solutions thus 
used are analgesic and may relieve the distressing neuralgic pains 
and tormina in the colon. Relief of these unpleasant symptoms may 
also be given by the use of chloretone solutions. The injection of 
olive oil and bismuth almost instantly relieves the painful effects 
of these solutions. 

The dangers of overdistention of an inflamed and ulcerated colon 
are difficult to overestimate. To avoid this, the author has devised 
a double or recurrent colon tube, made of soft rubber, and con- 
structed in such manner as to facilitate its introduction through the 
rectum and into the sigmoid. The tube having been properly in- 
serted, it is an easy matter to change the position of the patient, 
and by so doing irrigate the entire colon (Fig. 181). 

In some instances the tube is obstructed by the rectal or recto- 
sigmoidal valves, which may necessitate its introduction through 
the sigmoidoscope or proctoscope. In chronic cases especially has 
this difficulty been encountered, since in these a fibrinous infiltra- 
tion of these structures often exists, rendering almost impossible 
the use of an ordinary rectal tube. To ascertain whether or not the 
tube had coiled in the rectum, the operator can introduce the index 
finger, well anointed with the lubricant given below. After several 
unsuccessful attempts have been made, the proctoscope should be 
introduced and the tube inserted through it as shown in Fig. 182. 

A lubricant of the following formula is preferred by the author : 

I^ Pulveris tragacanthse gr. ccclxxxiv 

Phenolis . Til ccxl 

Glycerini 3rj 

Aquas destillatse q. s. ad Oij 

Misce. 
Shake up gum with enough alcohol to make thick paste. Add acid and glycerin. 
Shake well and add water all at once. Agitate vigorously. 

Dr. Louis LeRoy, of Memphis, has suggested the use of phenol- 
sulphonate of copper solutions for the colon irrigations. 

The author has used this chemical in the treatment of a number 
of cases, but is unable to state its exact degree of efficiency. It is 
a very powerful parasiticide, and its use is advised alternately with 
the formalin-boric solution. The strength of the copper solutions 
is 8 to 10 grains to each quart of sterile water. 

Ichthyol (10 per cent solution) applied locally to the mucous 



DYSENTERY 



289 



membrane, or gauze, saturated with the same solution, packed in 
the rectum, has seemed to exert a beneficial effect. 

It is well to mention here that an antidysenteric serum has been 




Fig. 182. — Position of patient for proctoscopy. Proctoscope introduced to facilitate the 
introduction of the colon tube. 

very highly recommended in the treatment of the malignant bacil- 
lary type of dysentery. 

My recent experience justifies the mention of mixed vaccines 



290 DISEASES OF THE RECTUM 

(Van Cott) in some of the chronic cases, with skin infections and 
associated fnruncnlosis and pruritus, or of the autogenous baete- 
rins, as advised by Murray, of Syracuse, who has made an exhaus- 
tive study of the bacteriology in some such cases. 

CHRONIC OR SECONDARY AMEBIC DYSENTERY 

All subacute or chronic cases of dysentery depend for their symp- 
toms upon an ulcerated and inflamed condition which will not yield 
to treatment. 

These cases have exacerbations and amelioration of symptoms. 
They often complain of constipation, which may extend through a 
period of weeks or even months. It is in these subacute and chronic 
cases that the proctologist is most often consulted. 

Such remedies as nitrate of silver, grains 30 to 60 to an ounce 
of sterile water, or a 20 per cent solution of argyrol, are applied, 
after first cleansing and antisepticizing the rectum and sigmoid 
with pledgets of cotton wrung out of hot formalin-boric solution 
(Fig. 183). 

A 30 per cent solution of lactic acid has also been used to cauter- 
ize the ulcerative areas. 

After these applications have been made, the bowel is sprayed 
with some neutral or alkaline solution to neutralize the excess of 
the silver or other solution used (Fig. 184). 

The bowel surfaces are then dried. Now, the insufflation of some 
non-toxic antiseptic powder, such as equal parts of boric acid and 
aristol, is advised. 

The symptom of iodism is an unpleasant one and may be readily 
produced by the instillation of drugs containing iodin into the rec- 
tum. Because of this, these remedies, such as aristol, bismuth- 
formic-iodid, and iodoform, have appeared most effectual when used 
just to the point of tolerance. 

When the amebic infection has become very chronic, or has ex- 
tended into all parts of the colon beyond the use of the local meas- 
ures just described, appendico-cecostomy should be performed, and 
the same fluids previously suggested should be used in irrigating, 
through the appendico-cecostomy opening. The fluid is allowed to 
pass out through the rectum into the catch basin, or a drainage tube 
may be inserted into the rectum. 



DYSENTERY 



291 



This plan of treatment was first advised by Dr. E. A. Corsons, of 
Savannah, Ga. 

In 1898, Dr. H. F. Harris stated that some years before Dr. Cor- 




Fig. 183. — Method of application of silver and other solutions to the ulcerated surfaces 
of the rectum and sigmoid. 



sons made this suggestion to him. Irrigations of the bowel with 
hydrogen peroxid through the artificial opening, thus established, 
were also advised. 



292 



DISEASES OF THE RECTUM 



About the year 1901, Dr. Robert Weir, of New York, while per- 
forming a colostomy for amebic dysentery anchored the appendix 
and irrigated through the stump with a saline solution. 






« 



Fig. 184. — Method of spraying rectum and sigmoid with solutions, and also of insufflating 
mucous surfaces with antiseptic powders. 

Shortly afterward, Dr. Meyer, also of New York, performed a 
similar operation. 

Dr. Tuttle, of New York, conceived the plan of allowing the ap- 



DYSENTERY 293 

pendix to remain undisturbed after anchorage for a sufficient time 
(three or four days) to establish adhesions about the proximal end 
before cutting away the distal portion, and using the appendiceal 
stump lumen through which to irrigate with the desired solutions. 

The author has practiced this last method and irrigated the colon 
with formalin-boric, copper phenolsulphonate, quinin, and iodin and 
thymol solutions with most gratifying results. It was observed, 
however, that the irrigations alone did not effect a cure. Topical ap- 
plications (through sigmoidoscope or proctoscope) were in all cases 
used in conjunction. 

The technic developed by the author combines the appendicostomy 
and cecostomy, and virtually makes an appendico-cecostomy. 

The mesoappendix is ligated below the distal branch of the ap- 
pendiceal artery; then the appendix is brought through a small 
stab wound about one inch above the anterior superior spine of the 
ileum, as advocated by Doctor J. A. Crisler, of Memphis, in 1906. 

The exact location of the stab wound is determined by the posi- 
tion of the head of the cecum, and the possible tension when the 
patient is in the erect posture. The author's technic involves the 
anchorage of the cecum, not the appendix, but leaves the stump of 
the latter through which the irrigations are practiced, avoiding 
pressure upon the same. The appendix may be immediately cut off, 
but to minimize the clanger of infection I think it is advisable to 
leave the same undisturbed for the first twenty-four or thirty-six 
hours, provided, of course, that no contraindications exist. 

AY hen this operation is completed, I insert a small sterile catheter 
to insure continued patulency and at the same time act as a dilator. 
The appendicostomy-tube, devised by Dr. Hirschman, later replaces 
the catheter for permanent use in irrigating. 

In a few cases the author was forced to perform rectal vagot- 
omies on account of obstruction to drainage, and to the insertion 
of the proctoscope or even the tube beyond the valves which were 
tightly stretched across the lumen of the rectum. This operation 
will rarely be found necessary. 



CHAPTER XIV 



PROLAPSE OF THE RECTUM IN CHILDREN 

Prolapse of the rectum is the descent, with or without protrusion, 
of one or all of the coats of the rectum, uncomplicated by any other 
diseased condition. Prolapse of the anus is usually understood to 
mean the descent and protrusion of either the mucous membrane 
alone or all of the coats of the anus and lower end of the rectum 
outside the anal aperture. 

Prolapse may be either partial or complete. Partial prolapse is 
the condition in which the mucous membrane alone protrudes, com- 
plete prolapse describing; the descent of all of the coats of the rec- 
tum. The complete variety is divided into three varieties, accord- 
ing to the degree or extent of the prolapse. 

Prolapse of the first degree is the condition in which the pro- 
lapsed portion begins at the anal margin, and the mucous membrane 
covering it can be seen to be continuous with the surrounding skin, 
there being no sulcus surrounding it. In complete prolapse of the 
second degree, it will be found that the descent begins at some point 
in the rectum above the sphincter and is extruded through the anal 
orifice, being telescoped, as it were, through the non-affected por- 
tion below. In this variety a distinct sulcus can be made out be- 
tween the prolapse and the margin of the anus. 

Prolapse of the third degree may begin in the upper portion of 
the rectum, or even the lower portion of the sigmoid, may descend 
into the lower rectal cavity, but as a rule does not protrude from 
the anus. This variety is also known as concealed prolapse (Fig. 
185). 

Inasmuch as the limitations of this work do not include those con- 
ditions whose relief requires surgical operations under general 
anesthesia, none of the conditions mentioned above will be treated, 
save the condition most commonly seen by the general practitioner 
— prolapse of the anus and rectum in children. The most frequent 
variety seen in children is that known as the partial or incomplete, 
and it consists of an eversion of the anal canal, carrying with it the 

294 



PROLAPSE OF THE RECTUM IN CHILDREN 



295 



mucous membrane covering the lower end of the rectum. It is a 
condition amenable in the vast majority of cases to non-surgical 
measures, when seen early and treated with patience and persist- 
ence. 

ETIOLOGY 

It is brought about most frequently by severe prolonged or undue 
straining efforts on the part of the child. Such diseased conditions 





Fig. 185. — Prolapse of the rectum, third degree. This shows the prolapsing rectum 
descending to the anus but not protruding. 

as the presence of a rectal polypus, hemorrhoids, foreign body in 
the rectum, hard constipated stools, pinworms, stone in the bladder, 
phimosis, diarrhea, excessive coughing or sneezing, accompanied by 
weakness of the sphincter muscle, are responsible at times ; but most 
common of all are the prolonged straining efforts at defecation. 

The practice so commonly in vogue among mothers in their ef- 
forts to train their children to regular habits of defecation has been 



296 DISEASES OF THE RECTUM 

responsible in the majority of cases for the production of prolapse 
of the rectum. The little patient is placed upon the toilet, vessel or 
chair, and is soon made to realize what is expected of him. Sitting 
in the semi-squatting position, which is most conducive to the emp- 
tying of the rectum, even of its own mucous membrane, for half an 
hour, or even all the morning (as has- happened in some cases which 
have come under the author's notice), the little one using all his 
efforts in order to accomplish his daily duty, gradually brings about 
a separation of the mucous membrane of the rectum, with accom- 
panying protrusion from the anus. 

In other cases, through extraordinary efforts of the abdominal 
muscles, the mesentery of the sigmoid becomes elongated, and an 
intussusception of the upper rectum and lower sigmoid takes place. 
Protrusion of the prolapsed bowel is very rare in this instance, and 
a condition known as concealed prolapse is produced and often goes 
undiagnosed for a considerable period of time. From an anatomical 
point of view, the straightness of the sacrum in children offers less 
support to the rectum than in adults, and in children who have been 
suffering from wasting diseases, the parts become so relaxed that 
practically all support is taken away from the rectum. 

SYMPTOMS 

When the rectum prolapses in children, it appears rather unex- 
pectedly. After a more or less long period of time, in which the 
"training" of the child has been going on, the mother is surprised, 
some fine day, by the appearance of a ring of red or purple-hued 
membrane surrounding the anus, the size depending upon the 
amount of rectum prolapsed. The longer the prolapse remains out- 
side the rectum, the more purple-hued it becomes from the inter- 
ference with the return circulation on account of the contraction of 
the sphincter. 

DIAGNOSIS 

The diagnosis is very simple, in fact, self-evident. The appear- 
ance of a ring of soft, velvety mucous membrane protruding from 
the anus is indicative of only one condition, that of prolapse. A 
polypus would be differentiated by its rounded form, harder con- 



PROLAPSE OF THE RECTUWI IX CHILDREN 



297 



sistency, and the presence of a pedicle extending inside the anus. 
Hemorrhoids, which are rare in children, would be gradual in on- 
set, of firmer consistency, forming separate masses, and would not 
exhibit the peculiar red or purplish appearance of prolapsed mu- 
cous membrane. On each successive occasion, when the bowel is 
protruded, more of the mucous membrane comes down, and in ag- 
gravated cases the entire rectum may be extruded. 

TREATMENT 

"When the protrusion first makes its appearance it may be re- 
duced in the following manner: The child is placed on its mother's 




Fig-. 186. — Prolapse of the rectum, first degree, showing radiating lines of cauterization. 



lap with the buttocks raised considerably higher than the head. A 
compress soaked in ice water placed against the prolapse will often 
be all that is necessary. Gentle pressure will in a few minutes, in 
most cases, cause a return of the prolapsed portion. Oftentimes 
simple digital pressure on one side of the prolapse while the but- 
tocks are separated with one hand, and steady pressure made with 
the finger of the other, will suffice. The other half is then treated 
in like manner, 



298 DISEASES OF THE RECTUM 

Where the prolapse has remained outside long enough to become 
swollen, edematous, or congested, and the sphincter has contracted 
upon it, it will often be very difficult to return the prolapse unless 
the sphincter has been relaxed by the injection of a local anesthetic. 
In order to relieve the congestion and shrink the blood-vessels, the 
employment of compresses, soaked with one to one thousand solu- 
tion of adrenalin chlorid and applied with firm pressure to the pro- 
trusion, has, in the author's hands, been found extremely satis- 
factory. The blood-vessels become constringed and the mass much 
reduced in size, and reduction is comparatively easy. 

Whenever pressure is used in this region, it should be firm but 
gentle, as it would be very easy to do serious damage if the manipu- 
lations were rough or violent. Wrapping dry absorbent cotton 
around the index finger, and pressing firmly against the prolapse 
and in the direction of the rectal canal will often return a prolapse 
with ease. The finger is withdrawn in a twisting manner so as to 
allow the cotton to remain in the rectum, from whence it is expelled 
Avith the next stool. 

If the child's habits are corrected, the bowel, in many cases, will 
not protrude again. In cases, however, where the protrusion recurs, 
a definite line of treatment must be undertaken in order to relieve 
the tendency to chrOnicity of the condition. Any existing cause, 
such as stone in the bladder, phimosis, piriworms, polypus, foreign 
body in the rectum, etc., must be relieved by proper surgical meas- 
ures. If the case is due to constipation, the child's dietary should 
be looked into and corrected. 

Where the case is one, however, where the prolapse has been 
brought about by the prolonged sitting at stool, with its coincident 
severe straining efforts, this method of training must be dispensed 
with. The child must be made to move its bowels in the recumbent 
position, either lying on its back or side, preferably the latter. It 
must not be allowed to have movements in the sitting posture while 
under treatment. The administration of white petroleum oil suit- 
ably flavored, in doses varying from ten minims four times a day in 
an infant, to a teaspoonful for the child of five or six years of age, 
should be resorted to in order to keep the stools soft and the intes- 
tinal canal well lubricated. It is important after the bowel move- 
ments to strap the buttocks together with strips of adhesive plaster. 



PROLAPSE OF THE RECTUM IN CHILDREN 299 

and iii some cases it may be advisable to keep a pad made of ab- 
sorbent cotton, wrapped with gauze, firmly against the anus. 

This treatment will be very successful if persisted in long enough. 
The author would advise two months as the average length of treat- 
ment in the average case. Any tendency toward diarrhea should be 
immediately looked after, and the dietetic cause for it discovered 
and corrected, for the violent peristalsis which accompanies diar- 
rhea is often productive of as bad, if not worse, results as the strain- 
ing efforts of constipation. 

Concealed Prolapse. — In some cases of constipation, so called, in 
infants, all efforts for successful treatment will fail, and the author 
would advise in these cases the examination of the infant's rectum 
by means of a small-sized proctoscope or a large cystoscope. Oc- 
casionally, this method of examination will be rewarded by the dis- 
covery of a prolapse of the third degree (Fig. 185), which extends 
down to the rectum but does not protrude. In these cases the in- 
fant will be very fussy and will strain until red in the face, but all 
that rewards his efforts will be a small quantity of mucus stained 
with fecal matter; and the only way in which the child's bowels 
can be emptied is by means of enemata. The same treatment as out- 
lined for the incomplete prolapse is indicated in this condition. 

The principal point in the prevention and the treatment of pro- 
lapse of the rectum in children is the education of mothers along 
the line of the so-called training of infants. While it is not the prov- 
ince of this work to go into the subject of infant feeding, neverthe- 
less, the author feels that if more attention is paid to the presence 
of sufficient hydrocarbon elements in the child's dietary, and the 
child is made to drink sufficient water, much good would result. 
Instead of forcing the little one to sit upon the toilet seat from half 
an hour to an hour and a half, or even longer, the child's bowels 
would then move with regularity and ease, and prolapse would be- 
come a very rare condition. The squatting posture as assumed by the 
aborigines is the best for the children. If after ten or fifteen min- 
utes at the stool the child does not have a movement, it is far better 
to insert a soap suppository or administer a small enema to tide it 
over occasionally than to indulge in the pernicious custom, seem- 
ingly so prevalent, of keeping the child on the seat for a prolonged 
period. 



300 DISEASES OF THE RECTUM 

When, in spite of strapping and. the proper control of the bowel 
movements, the prolapse still persists, it becomes necessary to do 
something more radical. The method which has been most satisfac- 
tory in the hands of the author, and which is particularly adaptable 
to prolapse of the rectum in children, is what is known as linear 
cauterization. This may be accomplished in two ways — -either by 
application of strong nitric acid or the use of the actual cautery. 
Neither method is applicable with entire satisfaction unless a general 
anesthetic is employed. Nitrous oxid, with or without oxygen, how- 
ever, can be used in these cases with perfect safety and. makes a 
very dependable and satisfactory anesthetic. 

Cauterization by Nitric Acid. — The child is placed in the lithot- 
omy position with the prolapse unreduced, and is placed under the 
influence of the nitrous oxid gas. The protruding mucous mem- 
brane is wiped dry, and a wooden applicator, one end of which has 
been wrapped with a very small quantity of absorbent cotton mois- 
tened with fuming nitric acid, is all that is necessary. The acid is 
applied in 4 to 6 radiating lines (Fig. 186), beginning at the upper- 
most portion of the center of the prolapsed mucous membrane at 
the lumen of the bowel, and with considerable pressure a line is 
drawn or painted to, but not touching, the mucocutaneous juncture. 
Four to six equidistant cauterizations are made in this manner, and 
an ointment composed of a dram of bicarbonate of soda to an ounce 
of petrolatum freely applied. A piece of rubber drainage tube, 
the size of a lead pencil, wrapped with gauze until it forms a plug 
or packing about % of an inch in diameter in its center and tapering 
at its extremities, is used to force the prolapse back into the rectum, 
and is left there for three or four days if possible. The little pa- 
tient's suffering after the operation is not very acute, but if there 
should be much pain, it should be controlled by suitable doses of 
codein hypodermically ; y 8 to % grains of codein will answer very 
nicely in children from % to 3 years old. 

The after-treatment consists in the same methods and procedures 
as those advocated above in regard to diet, defecation in the re- 
cumbent position, the strapping of the buttocks, etc. After three 
Aveeks the child may be allowed to resume defecations in the squat- 
ting position. In the first dressing immediately after the operation. 



PROLAPSE OF THE RECTUM IN CHILDREN 301 

it is wise to exert some pressure against the anus, by means of a 
suitable pad kept in place by adhesive-plaster straps. 

Linear Cauterization with the Actual Cautery. — The patient is 
prepared as described in the preceding paragraph, and when the 
prolapse is protruding to its fullest extent, a Paquelin cautery, 
armed with a blunt point, and heated to a white heat, is used for 
making the cauterization in the same manner as the nitric acid is 
used (Fig. 186). One should be careful to carry the cauterization 
through the mucous membrane and into the muscular layer, but 
should be extremely cautious about burning through the muscular 
tissue. The amount of destruction of tissue is more apparent than 
real; one must remember the object of the cauterization is to ac- 
complish the contraction of redundant tissues, and it is the con- 
tracting scar which invariably follows the use of the cautery, upon 
which Ave depend to accomplish the results. In this condition ice 
take advantage of the great contraindication to the use of the actual 
cautery in the surgery of the rectum, for we well know that the scar 
produced by a burn on mucous membrane invariably contracts to 
such an extent as to lessen the caliber of the rectum. The after-treat- 
ment, dressing, and packing are the same as described where the 
nitric acid is used as a cauterizing agent. 

"Where these methods fail, there is nothing left to do but one of 
the cutting operations under surgical anesthesia, and preferably in 
hospital surroundings. When such is the case, the operation had 
best be done by one who is specially trained in this line of work. 
and not by the general practitioner, as the operative and after-care 
often taxes the patience, skill, and ingenuity of even the trained 
specialist to accomplish the desired results. 



CHAPTER XV 

TEGHNIC OF THE USE OF LOCAL ANESTHESIA IN THE 
TREATMENT OF ANORECTAL DISEASES 

If any excuse or apology were necessary for the presentation 
of this work to the profession at this time, the subject matter 
contained in this chapter will be ample justification. The dan- 
gers, inconveniences, necessary confinement in bed, and detention 
from business, which must attend the use of general anesthesia 
in many so-called minor operations, have created a demand and 
constantly enlarging field for the use, in many departments of 
surgery, of local anesthetics. In the surgical treatment of diseases 
of the rectum and anus this is especially true; and while there 
are many diseased conditions of this region requiring surgical 
interference, the extent of which makes their operative treatment 
impossible without general anesthesia, there are, nevertheless, many 
of the more common diseases of this part of the body which are 
entirely amenable to surgical treatment under regional anesthesia. 

The development of the use of local anesthesia in the treat- 
ment of anal and rectal diseases has progressed to such a stage, 
that it is safe to say that at a conservative estimate fully 75 per 
cent of all cases of rectal and anal diseases are amenable to treat- 
ment without the use of general anesthetics. 

ANESTHETIC AGENTS 

Various anesthetic agents have been employed for the produc- 
tion of local anesthesia in this region, among which may be named 
the ethyl chlorid spray, and the injection of solutions containing 
quinin and urea hydrochlorid, cocain hydrochlorid, apothesin, 
betaeucain hydrochlorate and lactate, alypin, stovain, novocain 
chloretone, as well as plain sterilized water. 

Formerly, cocain, in solutions varying in strength from 4 to 
10 per cent, was used. Symptoms of an alarming nature fre- 
quently developed after the injection of but a few drops of even 

302 



TECHNIC OF LOCAL ANESTHESIA 303 

a 4 per cent solution, which clearly demonstrated the toxic prop- 
erties of the drug and the dangers of its indiscriminate use in 
strong solutions. Today we know that the extent of anesthesia 
produced depends, not so much on the strength of the solution, 
as upon the pressure anesthesia produced on the nerve-endings, 
by the amount of solution injected, rather than its strength. 

Today, therefore, practitioners who are still partial to cocain 
are using solutions for injection, varying in strength from Y 10 per 
cent up to % P er cent, and find the latter strength equal to the 
severest test. The author, after a trial of all of the anesthetics 
mentioned above, places his main reliance on apothesin for skin 
anesthesia, and y 2 per cent solution of quinin and urea hydrochlorid 
for infiltration of the tissues to be incised or removed. 

Solutions containing more than Y 2 P er cen t of quinin and urea 
hydrochlorid should never be used in or directly underneath the 
skin. Cases of skin necrosis and slough have been reported from 
the subcutaneous use of stronger solutions. As a matter of fact, 
better or more complete postoperative anesthesia can not be secured 
from stronger solutions. 

The strength of the apothesin solution varies according to the 
part to be anesthetized as well as on the amount of work to be 
done. For injection into the skin and for the anesthetization of 
the sphincterian nerves, % per cent solution is strong enough. 

For the distention of the tissues, for instance, in operating for 
fissure or internal hemorrhoids, a Y 10 per cent solution will suffice. 
Another important reason for my preference for apothesin is the 
fact that apothesin is less than one-sixth as toxic as cocain, and 
is fully as powerful in its anesthetic properties. 

My reasons for the use of quinin and urea hydrochlorid are 
that, in addition to its equality to cocain, apothesin, and eucain 
as an anesthetic, it is non-toxic, can be sterilized, and its anesthesia 
is prolonged for from two hours to several days after operation. 

Quinin and urea hydrochlorid is a double salt of quinin and 
urea, made by dissolving quinin hydrochlorid in hydrochloric acid, 
adding pure urea, filtering the mixture through glass wool, and 
allowing it to crystallize. It is soluble in its own weight of water 
and in alcohol. It has the action of quinin, is non-irritating when 
injected hypodermatically, and produces local anesthesia, lasting in 



■" 



304 DISEASES OF THE RECTUM 

some instances several days, depending- on the strength of the 
solution. 

Dr. V. M. Griswold, of Fredonia, N. Y., first called attention 
to the hypodermic nse of qninin as an efficient local anesthetic, 
and as being much safer than cocain, in July, 1896, before the 
Chautauqua County (New York) Medical Society. 1 Dr. G-riswold 
claims that his use of quinin as a local anesthetic is the result of 
experiments with various substances in the endeavor to find one 
equally efficient but less dangerous than cocain. 

In the Journal of the Arkansas Medical Society, for September, 
1907, Dr. Henry Thibault, of Scotts, Ark., in an article entitled, 
"A New Local Anesthetic," first called attention to the local 
anesthetic effects of quinin and urea hydrochlorid. He recom- 
mended the use of a 1 per cent solution for local injection, and 
from 10 to 20 per cent for local application to any mucous surface. 

The hydrochlorid of quinin and urea, being a water-soluble salt, 
is used in the South quite extensively for the hypodermic treatment 
of malaria. It was discovered that the site of injection of the 
quinin solution remained anesthetic for a considerable period of time 
following the injection. This fact has been taken advantage of, 
and the value of the discovery of a non-toxic substitute for cocain 
is being demonstrated by several workers at the present time. 

In an article in the Journal of the A. M. A., for October 23, 
1909, Hertzler, Brewster, and Rogers, of Kansas City, Mo., pub- 
lished a report of their work with this anesthetic during the pre- 
ceding six months, from which I will quote somewhat: 

They started with the 1 per cent solution recommended by Thi- 
bault. They found, as stated by him, that a perfect anesthesia is 
obtained, which lasts from four to six hours. The anesthesia is 
more complete than with cocain. They soon discovered, however, 
that disturbances in skin union sometimes occur. Hertzler noted 
particularly that in hernia operations there is some disturbance in 
healing of the skin wound which had not been noted after the use 
of cocain. The disturbance was not great, but the patient had to 
be kept in bed longer than after the cocain operation. The edges 
of the wound were indurated and thickened, but there was no pus 



^Buffalo Medical Journal, August, 1896, p. 32. 



TECHNIC OF LOCAL ANESTHESIA 305 

formation. The thickening appeared to be due to cellular in- 
filtration. 

Hertzler thereupon undertook to determine experimentally the 
cause of the induration. Experiments performed on rabbits showed 
that the thickening is not due to cellular infiltration at all, as was 
supposed on clinical grounds, but is due to the pure fibrinous 
exudate free from cells. This exudate was proved to be fibrin 
by Mallory and "Weigert's stain. The reaction appears, therefore, 
to be purely chemical in nature. The exudation of the fibrin begins 
to appear within a few minutes. In a general way it was de- 
termined that the amount of exudation depends on the strength of 
the solution used; the attempt was made, therefore, to determine 
a strength of solution which would not cause this exudation of 
fibrin. With % per cent solution the exudate is less than with the 
1 per cent, and with the % per cent solution only traces can be 
discovered. To what extent this fibrinous exudate is subsequently 
converted into fibrous tissue has not yet been definitely determined, 
but apparently nearly all is absorbed. 

In order to determine the subjective sensations of the injec- 
tion and to determine the question of a possible zone of hyperesthesia 
about the anesthetized zone, Hertzler studied the effect by injec- 
tion in the skin of his own leg. Injections of 1 per cent, % per 
cent, % per cent, and % per cent solutions, and an injection of 
plain water for control, were used in each series. The 1 per cent 
and Y 2 per cent solutions gave immediate and complete anesthesia 
without a particle of pain during its introduction. "Within a few 
minutes there was a distinct induration. With the % per cent 
solution anesthesia was not complete for a few minutes, but was 
then as complete as after the use of the stronger solution. The 
% per cent solution gave delayed anesthesia, but after a few min- 
utes was complete. In neither of these weaker solutions was in- 
duration noted on palpation. The water control caused intense 
pain on injection, and the anesthesia, at no time perfect, lasted 
only a few minutes. There was a zone of hyperesthesia one or 
two inches in width about the area injected. Curiously enough, 
the hyperesthesia seemed to be for touch and not for pain. 

The duration of the anesthesia in the 1 per cent and % per 
cent solutions was perfect for four or five days, and sensation 



306 DISEASES OF THE RECTUM 

in the y 2 per cent .strength was not restored to any great ex- 
tent for ten days, and in the 1 per cent solution sensation was 
not completely restored after two weeks. At no time was there 
the least pain, though the induration of the 1 per cent and % 
per cent solutions was yet marked at one and two weeks re- 
spectively. Quinin anesthesia, it will be seen, can be used for 
any operation where the use of local anesthesia is indicated. It 
has three very decided advantages over any other local anesthetic : 

1. It is non-toxic, and can be given in unlimited dosage. Brew- 
ster has used 100 grains intravenously within six hours in a patient 
suffering from pernicious malaria. 

2. The prolonged anesthetic effect. In many cases postopera- 
tive anesthesia has lasted from four to five hours to as many days 
and longer. 

3. Where the solution containing 1 per cent or over is used, 
the hemostatic effect produced by the deposition of fibrinous ex- 
udate is of extreme value in preventing postoperative oozing. 

The exudate being fibrin in the strict chemical sense, the usual 
natural processes of hemostasis are anticipated. The coagulum 
occurs, it is true, about and not in the vessels, and their occlusion 
therefore results from pressure from without. The important point, 
however, is that the effect lasts from seven to fourteen days, a 
time abundantly sufficient to allow healing by granulation to be- 
come well advanced. This is in marked contrast to the ephemeral 
influence of cocain and adrenalin, which act only by causing a con- 
traction of the muscular walls of the bloodvessels. 

The association of quinin and urea hydrochlorid with cocain, 
apothesin, eucain or any of the other anesthetic salts hitherto em- 
ployed, will be found eminently satisfactory in all cases of rectal sur- 
gery where suturing of the integument is not required. My ex- 
perience with this drug leads me to recommend it, on account of 
its several distinct advantages over any of the other anesthetic 
drugs upon which we have previously depended. 

It is soluble in water and can be sterilized. It is equal to cocain 
in anesthetic power and is absolutely non-toxic. It has a pronounced 
hemostatic action, and postoperative anesthesia lasts from four hours 
to several days. It is inexpensive and almost always available. 

The use of sterile water as an anesthetic in the treatment of 



TECHNIC OF LOCAL ANESTHESIA 



307 



rectal and anal diseases was exploited prominently a few years 
ago, and while the author's experience with it has proved to him 
that satisfactory anesthesia in certain cases can be produced by 
its use alone, he limits its use in his work at present to the oc- 
casional distention of internal hemorrhoids for demonstration in 
teaching only. The one objection which he has found to its 
indiscriminate use is the larger degree of discomfort to the patient 
at the initial injection and the large quantities of solution re- 
quired in some operations in the sphincterian region, causing such 
distortion of the tissues as not only to impede the work of the opera- 
tor but to displace the parts so that accurate work could not be 
done. 




Fig. 1S7. — Aseptic all-glass hypodermic syringe. 




Fig. 188. — Aseptic all-metal syringe, provided with extension for infiltrating through the 

proctoscope. 

It is well for the reader to realize that in "a pinch" sterile 
water can be used in lieu of any chemical anesthetic, and there are 
occasions, when he may be called upon to do work in an emer- 
gency, where the various chemical anesthetics may not be avail- 
able, when with an ordinary Irypodermic syringe and boiled water 
satisfactory anesthesia can be produced. 



INSTRUMENTS 

The principal instrument required for the production of local 
anesthesia is a hypodermic syringe with a capacity of two to four 
drams, which may be constructed entirely of either metal or glass 
(Figs. 187 and 188), so that it can be readily sterilized by boiling. 



308 



DISEASES OP THE RECTUM 



The needles used should be the finest that can be procured, 
and the points should always be kept sharp. A quick puncture 
with a sharp-pointed fine needle is almost painless, while the use 
of a larger-calibered needle with a short beveled point will cause 
considerable unnecessary discomfort to the patient. The piston- 
syringe package, constructed of glass and rubber, which many of 
the manufacturers of antitoxin supply, when sterilized by boiling, 
makes a fairly good substitute for the regular aseptic hypodermic 
syringe, and in the absence of the proper apparatus it may be 
used. The objection to it is the fact that the needles supplied 
with it are usually of larger caliber and not so sharp as they should 
be for this work. 

The solution used should be accurately prepared as to the per- 
centage of chemical anesthetic used. Where beta-eucain lactate 
is employed, the solution is made up and placed in an ordinary 
test-tube. It is sterilized by boiling over the flame of a Bunsen 
burner or spirit lamp, and then stoppered with absorbent cotton 
and allowed to cool. The solution is prepared freshly for each 
operation. The quinin-urea solution is prepared in like manner 
when the tablets are used. 



GENERAL TECHNIC 

The patient is prepared for the operation as follows: 
Twenty-four hours before the operation, he is given a brisk 
cathartic and is instructed to partake of nothing but liquid food 
thereafter. On the morning of the operation the bowels are washed 
out by means of a large soap enema, and he is directed to report 
at the office about one-half hour before the time for the operation. 
He is then given a quarter of a grain of morphin or two grains of 
codein by mouth. 

When ready to operate, the patient is placed upon the table in 
the left lateral position, the left leg extended and the right well 
flexed. The lower clothing is removed or placed well out of the 
way, and the patient covered with clean sheets. The anus and 
perineum are shaved and scrubbed with liquid antiseptic soap, then 
washed with a 1 :1000 solution of iodid of mercury, which is washed 
off with sterile water, and a compress of alcohol applied. If one 



TECHXIC OF LOCAL ANESTHESIA 



309 



prefers the iodin-alcohol method of skin sterilization, it is equally ap- 
plicable. A point one-half inch below and posterior to the posterior 
commissure of the anus is selected. A swab moistened with pure 
carbolic acid (Fig. 189) is applied to lessen the pain which ac- 
companies the introduction of the needle. Wherever it is possible, 




Fig._ 189. — First step in all operations under local anesthesia — application of carbolic acid 

to point of puncture. 

the index finger of one hand, protected by a finger cot or gloved, 
and well lubricated, is inserted in the anus, and the sphincter is 
pulled downward and backward. The syringe, containing about 
one dram of % to % P er ceut solution of apothesin, with a fine sharp- 



310 



DISEASES OF THE RECTUM 



pointed needle about two inches in length attached, is held in 
the other hand. The needle is inserted quickly, just underneath the 
skin, and 6 to 10 drops of the solution slowly injected. One should 
be extremely careful about injecting the solution too quickly, as this 
part of the procedure is the most painful and often needlessly causes 
suffering, particularly to the timid and neurotic patient. The point 
of the needle is then passed inward and laterally, going down to- 
ward and into the external sphincter muscle, which, guided by the 
finger in the rectum, is brought down toward the needle. The 
point of the needle should be kept about one-half inch from the anal 
aperture and the injection is carried up along the right postero- 




Fig. 190. — Exact point of puncture for the injection of local anesthetics for dilating the 
external sphincter. With the patient in the lateral position, a point from )4 to J4 inch 
posterior to the posterior commissure of the anus is chosen for the first injection. 



lateral quadrant (Fig. 191) of the anus for about three-fourths to 
an inch. The needle is then retracted to the point of puncture but 
not withdrawn. It is then pushed up on the left side in the same 
manner, injecting the opposite side so that when the injection is 
completed the wheal of infiltration is U-shaped, the apex being at 
the point of puncture (Fig. 192). 

This te clinic allows of the anesthetization of the sphincterian 



TECHNIC OF LOCAL ANESTHESIA 



311 



nerves of both sides from but a single puncture. Care should 
be taken lest the rectal wall be punctured, but with the index 
finger of one hand in the anus during this procedure, such an 
accident should not occur. The anesthetization of the anterior 
sphincterian nerves is accomplished in a similar manner, but is 
only required where a pathological condition on the anterior anal 
wall is to be operated (Fig. 193). 




Fig. 191. — Quadrants of the anus. 

1. Right anterolateral quadrant. 

2. Left anterolateral quadrant. 

3. Right posterolateral quadrant. 

4. Left posterolateral quadrant. 



In operations for multiple internal hemorrhoids, or other pro- 
cedures, where the complete exposure of the field obtained by the 
use of the four triangular forceps is desired (Fig. 196), the entire 
circumanal circumference must be infiltrated. 

Sufficient relaxation of the anesthetized sphincters (Figs. 195- 



312 



DISEASES OF THE RECTUM 



196) can be thus secured to perform any operation described in this 
volume. 

Complete divulsion of the sphincter can very rarely be accom- 
plished by this means, and is not ever necessary, but the dilatation 
will be amply sufficient for our purposes. 

The vibrator (Fig. 194), is a very convenient, but not at all 
necessary, apparatus to have at hand, as the dilatation can be 







i 



Fig. 192. — Showing the amount of distention necessary in anesthetizing the sphincters. 



more quickly and evenly accomplished by its use. In its ab- 
sence, however, one may use the index fingers of both hands, pro- 
tected by finger cots or rubber gloves, and by a gentle to-and-fro 
massaging movement, gradually assist relaxation and dilatation in 
a very satisfactory manner. One should never use any of the 
dilating rectal speculums in the dilatation of the sphincter. The 
fingers are far better dilators, and can do no damage with intel- 
ligence and care behind them to guide. 



TECHNIC OF LOCAL ANESTHESIA 



313 



TECHNIC IN SPECIAL CASES 

The technic for operating for the various conditions amenable to 
operative treatment under local anesthesia will be found described 
more in detail in their respective chapters, while the differences 
in technic of anesthetization will be taken up below. Suffice it to 
say, however, at this point, that no operation upon the anus or 
rectum should be undertaken under local anesthesia, which will re- 
quire extensive dissection or over twenty minutes of time for its 
completion. 




Fig 1 . 193. — Exact point of puncture for anesthetizing anterior sphincterian nerves for 
dilatation of the external sphincter. 



External Hemorrhoids. — If the hemorrhoid is entirely external 
and is not complicated by any other anal condition, it will not be 
necessary to anesthetize the sphincter. After the usual prepara- 
tion for the operation, the most dependent hemorrhoid is injected 
from its base with % per cent solution of apothesin, about 20 to 30 
minims being used directly under the skin. If further distention 
is required in order to produce complete anesthesia, Y 2 per cent 
quinin-urea solution may be used for the deeper injection. After 



314 



DISEASES OF THE RECTUM 



five minutes the skin may be incised painlessly, and the operation 
performed. Where more than one hemorrhoid is to be operated, 
they should all be anesthetized at once, and operated in turn if the 
operator is rapid in his work. 

Acute Thrombotic Hemorrhoids. — The acute thrombotic hemor- 
rhoid is usually single, occurring just at the anal margin. After 
being prepared for operation, eight or ten drops of % per cent 
solution of apothesin or % per cent quinin and urea solution is 




194. — Posture and method of producing dilatation of the sphincter ani by the use 
of a portable vibrator, armed with a cone-shaped vibratode. 



injected just beneath its outer covering, whether skin or mucous 
membrane, care being taken not to inject deeply and into the clot. 
Sufficient solution should be used to distend the tissues over the 
clot and blanch them to Avhiteness. It may then be incised painlessly, 
and the clot turned out, It is well after the turning-out of the clot 
to inject the tissues beneath it, and examine carefully, as usually 
more clots will be found beneath the first, which must be removed 
in like manner. 



TECHNIC OF LOCAL ANESTHESIA 



315 



Perianal Abscess. — In those cases of perianal abscess not ex- 
tensive enough to require general anesthesia for their operative 
treatment, the use of a local anesthetic is well adapted. The tech- 
nic in injection is the same as that outlined above for throm- 
botic hemorrhoids. The reader is cautioned to make his injection 
very carefully, so as not to perforate the abscess cavity with the 
needle. The solution must be injected into the skin itself and 
directly under it. After waiting at least five minutes for anesthesia 
to take place, the abscess may be opened with absolutely no pain. 




Fig. 195. — Amount of dilatation of the sphincter under local anesthesia. This drawing, 
made from a photograph of one of the author's cases of internal hemorrhoids, well 
illustrates the amount of dilatation of the sphincter that may be produced by local anes- 
thesia. While complete divulsion is rarely possible or necessary, sufficient relaxation is 
here secured to remove successfully the internal hemorrhoids shown in the drawing. 



Anal Fissure. — In all eases of fissure, the sphincter should be 
anesthetized thoroughly. In many cases where the fissure is situ- 
ated low down, the anesthetic solution injected for the anesthetiza- 
tion of the sphincter will also be sufficient for the incision or ex- 
cision of the fissure as well. "Where the fissure is more extensive 
and with an indurated base, or is located at some other portion of 
the anus than its usual site, the posterior commissure, it must be 



316 



DISEASES OF THE RECTUM 



injected separately. A % per cent solution of apothesin, or Y 2 
per cent solution of quinin and urea hydrochlorid, may be used. 
The syringe should be filled. The needle should be inserted about 
one quarter of an inch below the outermost extremity of the fissure 
or beyond the sentinel pile when one is also present. 




196. — A good idea of the anesthesia and relaxation produced by the technic outlined. 



The skin and mucous membrane surrounding the fissure or in- 
duration, as the case may be should be infiltrated to such an ex- 
tent that the fissure is raised on a white waxy -looking mound and 
lies, as it were, on a water-bed. It may require as much as three 
drams of solution, but distention of the tissues is essential before 



TECHXIC OF LOCAL ANESTHESIA 317 

thorough work can be done. Anesthesia should be carried below 
the base of the fissure for at least a quarter of an inch. 

Fistula and Sinus. — The only variety of fistula in which it is 
advisable to use local anesthesia as a routine measure is that of a 
simple, shallow, complete fistula whose course is direct and not 
branching. An external or internal sinus whose opening is not 
over one inch from the anus, and whose extent can be accurately 
gauged, may be opened under local anesthesia. As a general prop- 
osition, with the exception of the three varieties mentioned, general 
anesthesia (nitrous oxid and oxygen whenever possible) should be 
used in operations for anal fistula and sinus. The sphincter should 
be anesthetized in all cases. The skin and mucous membrane above 
the fistula should be infiltrated with the % per cent apothesin 
solution, and then by successive injections the entire fistulous tract 
surrounding, with the injected anesthetic fluid. The infiltration 
should be carried to the point of blanching. The operation then 
may be proceeded with as outlined in the chapter on fistula. 

Hypertrophied Anal Papillae. — In cases where hypertrophy of the 
anal papilla? is not accompanied by a tightly contracted sphincter, 
it is possible to remove the papillae under local anesthesia without 
relaxation of the sphincter. It is advisable, however, in order to 
overcome the tenesmus and painful spasmodic contractions of the 
sphincter following any operation in the anal canal, to anesthetize 
the sphincter as a general rule in removing these papilla?. Where 
this is done the anus is held open by means of a retractor, and 
each papilla is injected from base to apex with the % per cent 
apothesin or quinin-urea solution. It may then be removed pain- 
lessly, and each successive one injected in turn before removal. 

"Where the sphincter is not anesthetized, the use of a short 
anoscope with an oblique opening, such as has been described by 
the author, will be required. The papilla, as it hangs down or 
projects into the opening of the anoscope, is injected by means 
of a long needle attached to the hypodermic syringe, and injected 
as described above. Where it is desired to open the crypts of 
M!orgagni as well, the needle should be carried up for half an inch 
or so, when after the removal of the papilla, the crypt can be split 
open at will. 

Hypertrophied Rectal Valves. — In operating for the section of 



318 DISEASES OF THE RECTUM 

hypertrophied Houston's valve, the dilatation or relaxation of the 
sphincter, as outlined above, is often the only part of the operation, 
where a local anesthetic is required. The valves themselves are 
very poorly supplied with sensory nerves, and as a result, incision 
is painless. In some cases, however, there is some sensitiveness 
to pain; so it is wise in all cases to be on the safe side, and 
apply by means of an applicator bent at a right angle a 2 per cent 
solution of apothesin or beta-eucain to both upper and lower sur- 
faces of the valve. After waiting two minutes, operation may be 
begun. 

Removal of Foreign Bodies. — Oftentimes small splinters of shell, 
bone, pins, or other swallowed foreign bodies will traverse the 
entire gastrointestinal tract without doing any injury or becoming 
lodged, until they reach the lower end of the rectum, when they 
impinge against the rectal aspect of the mucous membrane cover- 
ing the sphincter muscle, or lodge in one of the crypts. By their 
constant irritation, they cause spasm of the muscle and intense 
suffering. On account of the tonic contraction of the sphincter, 
which is caused by this irritation, any attempt at the insertion 
of a proctoscope or even the finger is usually futile. The dilatation 
of the sphincter by means of the technic outlined above is nowhere 
more applicable than in this class of cases, and not only such foreign 
bodies as have been mentioned, but fecal concretions and impactions 
of considerable size as well, can be removed without the employ- 
ment of a general anesthetic. 

Removal of Benign Perianal Growths. — Small benign growths situ- 
ated at or near the anal orifice, such as dermoids, sebaceous cysts, 
lipomata, or condylomata, are very satisfactorily removed under 
local anesthesia, with the following technic: 

After the parts are cleansed, shaved, and sterilized, condylomata 
are removed by infiltration of the underlying skin with % per 
cent solution of apothesin. "When anesthesia is complete, the af- 
fected skin is cut away and the wound either sutured with in- 
terrupted silkworm or allowed to remain open to heal by granula- 
tion. Boro-chloretone powder is then applied, and the parts covered 
with a gauze dressing. In the case of a dermoid, sebaceous cyst, 
or fatty tumor, the technic is the same for the removal of any of 
the three varieties. The skin covering the tumor is first injected 



TECHNIC OF LOCAL ANESTHESIA 319 

with Y 2 P er cen t solution of apothesin, a wheal or welt being formed 
over the proposed line of incision. The incision is made, and the 
tissues above and surrounding the tumor infiltrated with the apo- 
thesin solution or % per cent solution of quinin and urea hydro- 
chlorid, when the dissection and removal of the growth can be 
accomplished easily, with forceps and scissors. Care should be 
taken in the case of a cystic tumor not to puncture the cyst wall 
with the injecting needle, and in the excision of the growth to be 
sure to remove all of the sac. If this is not done, recurrence is 
likely. 




Fig. 197. — Wales rectal bougie. This is made of flexible rubber and provided with a 
canal, through which the irrigation may be given, and which allows the entrance of 
atmospheric air and escape of gas during its introduction. There are twelve different sizes. 

Posterior Internal Proctotomy for Annular Stricture Situated in 
the Anal Canal or Not Over an Inch Above the Anorectal Juncture. — 

With the patient in the left lateral position, and prepared for op- 
eration, the region posterior to the anus, anal canal, and stricture 
is infiltrated with % per cent solution of apothesin or quinin and 
urea hydrochlorid. After waiting five minutes for anesthesia to 
take full effect, the stricture is divided in the posterior median 
line down to the rectal Avail with a sharp scalpel, a piece of gauze 
inserted, and the operation is complete. The author's technic for 
rectal valvotomy by the use of the rubber ligature may be substi- 
tuted for the incision, if the caliber of the stricture is sufficiently 
large to admit the ligature carrier. After operation, the recur- 
rence of the stricture is prevented by the introduction of Wales' 



320 



DISEASES OF THE RECTUM 



bougies (Fig. 197) up to size No. 12, twice a week at first, and at 
increasing intervals until complete healing has taken place. 

After carefully perusing what has been said regarding the em- 
ployment of local anesthesia, and bearing in mind the contraindica- 
tions and objections, as outlined in the following chapter on Limi- 
tations of Local Anesthesia, other diseased conditions of not only 
the rectum and anus, but in other parts of the body, will present 
themselves, in which the employment of local anesthesia will be 
found very advantageous; and the results obtained therefrom fully 
as successful as where, heretofore, the employment of general anes- 
thesia has been thought absolutely necessary and indispensable. 

In the last three or four years, the author has employed the 
American-made local anesthetic apothesin in preference to those 
made "by the enemy." He is happy to state it is equal in every 
way to the best of the foreign-made drugs, and in many ways 
superior to all. Any of the standard anesthetic salts may be em- 
ployed in practically the same strengths as apothesin, and the in- 
dividual preference of the operator must govern his choice of local 
anesthetics. 



CHAPTER XVI 

LIMITATIONS OF LOCAL ANESTHESIA AND OFFICE 

TREATMENT AND INDICATIONS FOR 

OTHER MEASURES 

While the primary object of this work has been to bring be- 
fore the profession the advantages to be gained from the treat- 
ment of various rectal diseases in office practice, and to demonstrate 
the advantages of the use of local anesthesia in the treatment of 
many of the more common conditions met in connection with the 
treatment of diseases of the anus and rectum, it has been thought 
wise to utter a warning note, lest the reader be led away by over- 
enthusiasm. 

While the author believes that the field for the employment of 
local anesthesia in rectal surgery, as well as in other branches of 
practice, is rapidly widening, he wishes to impress upon the reader 
that this field has definite limitations and that there is and always 
will he, a large class of cases whose successful treatment requires 
more radical measures, which only can be employed by the aid of full 
general surgical anesthesia. 

If the reader has carefully read what has been written upon 
means and methods of diagnosis, and has noted in the various 
chapters following the class of cases in which the author advo- 
cates the use of non-surgical measures and the employment of 
local anesthesia, he will have noted that the methods of treat- 
ment advocated are confined to a very definite class of cases. 
All of the conditions treated of have been located either at, or 
in the immediate vicinity of, the anal canal, or were those af- 
fections of the mucous membrane of the rectum or lower sig- 
moid which are accessible to treatment through the proctoscope 
or sigmoidoscope. 

The first thing one should remember, before commencing the 
treatment of any pathological condition found in the region of 
the anus, is that, until a careful exploration of the entire rectal 
cavity has been made, and every portion of it examined with the 

321 



322 DISEASES OF THE RECTUM 

eye, he has not made a diagnosis, and has no right to treat the 
patient nntil he has. It would be a sad and unfortunate dis- 
covery for the physician who has been treating an anal ulcer, 
polypus, or pruritus, or hemorrhoids to find after several weeks, 
that the condition under treatment was merely secondary to a 
multiple colonic- polyposis, an extensive ulceration higher up in 
the rectum, a stricture, or malignant disease (Frontispiece). 

GENERAL CONTRAINDICATIONS TO LOCAL 
ANESTHESIA 

In women, suffering from pelvic troubles which may require 
laparotomy for their relief, the removal of any minor rectal con- 
dition present under local anesthesia had better be postponed, and 
the rectal or anal condition treated at the time of laparotomy. 

In patients suffering from irregularity or interruption of their 
normal bowel movements, it is wiser to exclude by careful ab- 
dominal examination, and the use of fluoroscopic examination and 
stereoscopic radiographs taken in both the upright and prone po- 
sitions, any possibility of chronic intestinal obstruction due to some 
abdominal growth, ptosis, displacement, or adhesions, than to at- 
tempt to relieve the patient by means of rectal dilatation and mas- 
sage. 

Every patient presenting himself with a fissure or ulcerative 
condition of the anal canal should be carefully questioned as to 
the possible history of previous syphilitic infection. The presence 
of gonorrheal discharge is a contraindication to operative meas- 
ures until the discharge is remedied. In women, a purulent vag- 
inal discharge as well as the menstrual flow is, of course, a con- 
traindication. 

Patients suffering from profound anemia are always bad sub- 
jects for operation at one's office under local anesthesia, and a 
history of hemophilia should always be excluded before office 
operations. Patients of a highly neurotic temperament and hys- 
terical females are best operated at home or in the hospital, and 
often under general anesthesia. In other words, the suitable cases 
for office treatment are those suffering from diseased conditions, whose 
pathological source is located on either the mucous surface of the 



LIMITATIONS OF OFFICE TREATMENT 



323 



rectum and lower sigmoid, and are definitely circumscribed in area 
and not of a malignant, syphilitic, or tubercular type; or lesions oc- 
curring at or around the anal orifice, whose outlines can be definitely 
marked out by the diagnostic means outlined in the fore part of the 
booh. 

CANCER OF THE RECTUM 

A great satisfaction to the practitioner, who as a routine measure 
makes a proper rectal examination of his patients whose symptoms 
would seem to indicate it, is the discovery of commencing malignant 
disease early enough to allow of the removal of the primary focus, 
and to save the patient's life. As has been said before, a history 




Fig. 198. — Proctoscopic view of carcinoma, situated just below the juncture of rectum and 

sigmoid. 

of rectal hemorrhage, however slight, is an imperative demand for 
complete exploration of the rectal cavity, and the most important 
condition for which to be on the lookout, which makes itself mani- 
fest early by rectal hemorrhage, is cancer. It is in this condition, 
above all others, where an early complete proctologic and sig- 
moidoscopic examination will achieve brilliant results, if the find- 
ings therefrom will result in an early operation for the removal 
of the growth. It is the same with malignant diseases in this part 
of the body as in all others — if the surgeon can only get at them 
early enough to thoroughly eradicate, he can relieve them with a 
pretty definite hope of permanent cure. 



324 



DISEASES OF THE RECTUM 



Inasmuch as rectal cancer most frequently occurs in the lower 
part of the organ, the early operation and complete removal are 
productive of much good. Some of the early symptoms of com- 
mencing cancer of the rectum or sigmoid are flatulence with colicky 
pains, diarrhea, alternating with constipation, tenesmus, increased 
mucous discharge, which is usually offensive in odor, and hemor- 
rhage. This hemorrhage is very slight at first, often showing a few 
blood streaks with the mucus, or small passages of blood either 




Fig - . 199. — Carcinoma shown in the preceding illustration, drawn from specimen removed 

by operation. 

with the stool or occasionally between bowel movements. The nearer 
to the anus the cancer is located, the earlier in the disease the hemor- 
rhage, on account of the traumatism to the growth caused oy the 
passage of the feces. Cachexia, loss of weight, and impairment of 
general health are not early signs of rectal cancer. The indican 
reaction is usually present in urine in cancer, while it is absent 
in ordinary diarrhea. 

Diarrhea which persists for some time, which is accompanied 



LIMITATIONS OF OFFICE TREATMENT 



325 



by the presence of blood, however slight, should be regarded as 
suspicious, and the patient carefully watched. When one con- 
siders that 50 per cent of all cancers occur in the gastrointestinal 
tract, and that 16 per cent of all cancers of the digestive tract 
occur primarily in either the rectum or sigmoid flexure, one com- 
mences to realize the importance of examining every case which 




Fig. 200. — Cancer of the rectum, with multiple fistulas. This drawing, made from a 
photograph of a case referred to the author, tells a pathetic story. The patient, a woman 
aged 52, suffering from various digestive disturbances and the appearance of blood with the 
stool, made her own diagnosis of '"bleeding piles;" after six months of self-treatment, she 
consulted an irregular advertising quack, who confirmed her diagnosis of "hemorrhoids," 
and proceeded to "absorb the growth by electricity." When her money ran out she was 
sent home cured. Her condition one month later, when seen by the author, is illustrated 
above. The area of infiltration involved the entire anus, posterior wall of the vagina, and 
all of the perineal wall between. Her perineum was riddled with abscesses and fistulas. The 
rectum and vagina communicated through a large rectovaginal fistula, and the posterior wall 
of the bladder was infiltrated. The case was hopeless, and she died shortly afterward. 



presents a history of rectal hemorrhage, however slight, no mat- 
ter Avhat the age or general appearance of the patient. 

Well-authenticated cases of cancer of the rectum have been 
found in cases as young as fifteen vears of age. To show how 



326 DISEASES OF THE RECTUM 

much more frequently cancer is prone to locate in this part of 
the body than is generally supposed, it may be stated that Boas 
found in 500 cases of cancer of the digestive tract, 83 cases of 
cancer of the rectum. In the personal practice of the author, 
very frequently patients are brought in by practitioners, many of 



/0$d 



Fig. 201. — Cancer of the rectum. This specimen, which includes the entire rectum and 
lower portion of the sigmoid, being twelve inches in length, was removed by the author 
by the perineal method, the sphincters being preserved. This case will illustrate the value 
of early diagnosis and prompt operative interference in cancer of the rectum. The patient, 
aged SO, suffered from gradually increasing disturbances of the digestive functions for about 
six months. The symptoms gradually grew worse, and she noticed that her stools were 
becoming smaller in caliber, and accompanied by a small quantity of blood. She consulted 
her physician, thinking that she had hemorrhoids. He immediately made a proctoscopic 
examination, and discovered just below and extending to the rectosigmoidal juncture a 
crater-like ulceration with raised edges projecting into the lumen of the bowel. A diagnosis 
of rectal cancer was made and the case referred to the author for operation. There was no 
extrarectal involvement, and the complete extirpation of the diseased rectum and lower 
sigmoid was followed by a rapid recovery of the patient. Four years after the operation 
she reported herself in perfect health, with no signs of recurrence. 

whom really try to do conscientious work, with unsuspected can- 
cer of the rectum. Many of these patients are in the forties, 
present robust appearance, and come with a history of some bleed- 



LIMITATIONS OF OFFICE TREATMENT 



327 



ing from the rectum from which they make their own diagnosis 
of "bleeding piles." They also complain of some disturbance of 
bowel movements, either constipation or diarrhea, and disturbed 
gastric and intestinal digestion, and occasionally a not very well- 
defined aching in the sacral region. 

In many of these cases proctoscopic (Figs. 198, 199) and sig- 




Fig. 202. — Cancer of the rectum. Same as the preceding. Interior view of the specimen. 
(The lettering on the preceding specimen corresponds to that below.) 
A. Point of amputation from the anus. 
R. Rectum. 
X. Cancer. 
S. Sigmoid flexure. 



moidoscopic examinations have demonstrated the presence of can- 
cer of the rectum, so far advanced as to cause almost complete 
occlusion of the lumen of the bowel, and too far advanced to 
extirpate with any hope of cure. It is the unfortunate expe- 
rience of many proctologists to be called upon to inform many 
of these patients of their hopelessness, and it is with the hope of 



328 DISEASES OF THE RECTUM 

bringing the profession in general to realize the importance of 
examination of the rectal cavity in all cases presenting the symp- 
toms just mentioned above, that so much stress is being laid on 
the importance of early examination of the rectum by the general 
practitioner (Figs. 200-202 and Frontispiece). 

ULCERATION OF THE BOWEL 

Cases of ulceration of the bowel involving more than one cir- 
cumscribed area which have become chronic, as well as the very 
extensive ulcerations due to the specific infections like tubercu- 
losis and syphilis, are not suitable cases for office or local treat- 
ment. It has been found in the experience of most proctologists 
that the only satisfactory way by which such cases may be cured 
is by "sidetracking" the fecal current by means of a temporary 
colostomy. This removes the mechanical as well as the bacterial 
irritation from the ulcerated surfaces and puts the parts at physio- 
logic rest; after which irrigations and other suitable therapeutic 
measures can be applied from above, as well as below. These cases, 
however, require more or less confinement in bed or in the house, 
and are best treated only in the surroundings which the modern 
hospital can best supply. 

While it is true that colostomy can be performed under local 
anesthesia, as the author has demonstrated in several cases, it 
is hardly to be advised to be performed by the general practi- 
tioner or included in the same class as the operative measures or 
diseases mentioned in the foregoing chapters. 

STRICTURE OF THE RECTUM 

No case of stricture of the rectum should be treated, whether 
by dilatation, incision, or ligature in office practice, unless it 
is situated within the first tAvo inches of the anorectal canal, and 
is not smaller in caliber than the circumference of a No. 10 
Wales bougie. Even then, its situation, consistency, structure, 
and relation to the rectal walls and impinging organs should be 
definitely ascertained by radiographic, digital, and instrumental, 
as well as ocular, examinations. Great caution must be observed 
in using forcible dilatation in any case of stricture of the rectum, 



LIMITATIONS OF OFFICE TREATMENT 329 

no matter how elastic the stricture may seem. Accidents have 
been reported where the rectum has been torn through, and the 
peritoneal cavity entered with fatal results, from the simple dilata- 
tion of large-calibered strictures by means of the Wales bougie. 
Cases of "stricture," due to unusual infiltration of one of Hous- 
ton's valves, or strictures of the umbrella type, can be easily 
divided by means of the author's rubber-ligature operation, as 
applied to hypertrophic d rectal valves. 

Where the administration of nitrous oxid with oxygen is so 
easy, and attended with practically no danger, its use is to be ad- 
vocated in those cases where operation of a short duration is all 
that is required, for which general anesthesia is absolutely neces- 
sary. 

RECTAL ABSCESSES 

While, as has been pointed out in a preceding chapter, some 
circumanal and perirectal abscesses are amenable to treatment, 
within certain limitations, under local anesthesia, abscess forma- 
tion may go on to such a point, where it is absolutely necessary 
to do a more extensive operation than is possible under local 
anesthesia. Certainly no abscess which extends above the levator 
ani muscle should ever be opened under local anesthesia; nor 
any abscess in the ischiorectal region, in which there is any doubt 
as to the operator's ability to obtain a large and free drainage 
opening by means of incision without curetting. Owing to the 
ease with which it enlarges in the ischiorectal region, it is a safe 
plan not to attempt to open any abscess under local anesthesia, if 
it has become larger than a hen's egg in size, unless a definite 
point of fluctuation and softening can be detected at a point 
well outside the sphincters. 

ANAL FISTULA 

No case of anal fistula which has more than one channel, or 
whose limits can not be definitely made out by digital examina- 
tion, should be opened under local anesthesia. In fact, the only 
safe way is to obtain a stereoscopic radiograph after the injec- 
tion of bismuth paste. Only the simple, direct, complete, or ex- 
ternal and internal sinuses or submucous fistulae, are amenable to 



330 



DISEASES OF THE RECTUM 



operation under local anesthesia, and in ease of doubt, nitrous oxid 
or ether should be employed. One never can tell how high, or 
how extensive, a dissection may be required for the complete re- 
moval of a fistulous tract, or which is the ideal operation, unless 
he is guided by a good set of stereoscopic radiographs. 



HEMORRHOIDS 

In operating for hemorrhoids under local anesthesia, one must 
be extremely careful in the selection of cases. Hemorrhoids, com- 
plicated with fistula, extensive ulceration, complete rectal prolapse, 
or abscess, are best treated only under general anesthesia. Ex- 
ternal hemorrhoids and acute thrombotic hemorrhoids can almost 
invariably be removed under local anesthesia, fully as satisfactorily 
as by the use of a general anesthetic. In the treatment of internal 
hemorrhoids and externo-internal hemorrhoids, however, there is a 
limit beyond which it is possible to go, but not wise. 

The author has yet to see a case of internal prolapsing hemor- 
rhoids which he has not been able to remove under local anesthesia. 
For the occasional operator, however, he would lay down the fol- 
lowing rules : In all cases of internal hemorrhoids where not more 
than five or six separate hemorrhoidal tumors are present, whether 
prolapsing or not (Fig. 133), operation under local anesthesia is 
the method of choice. Where more than six distinct hemorrhoidal 
tumors are present, or where there is a great deal of rectal pro- 
lapse complicating, their removal under nitrous oxid and oxygen 
anesthesia is advised. Where, however, it is deemed unsafe or in- 
expedient, or where the patient absolutely refuses to take a general 
anesthetic, the more severe cases can be operated on under local 
anesthesia by operating at several different sittings, removing two 
or three hemorrhoids at a time, and then in a month or so re- 
moving more, eventually accomplishing the complete removal of 
all the hemorrhoids in three or four months and by as many opera- 
tions. In some patients suffering from cardiac, pulmonary, or renal 
disease, such a method may have to be followed where the adminis- 
tration of a general anesthetic would be absolutely prohibited. 

In cases suffering from interno-external hemorrhoids, where there 
are more than five or six separate tumors, their removal should be 
easily performed by an expert, but where one is in doubt as to his 



LIMITATIONS OF OFFICE TREATMENT 331 

ability to do so, the same result may be accomplished in two sittings, 
by removing the external portions at one operation, when, with 
these out of the way, the internal ones can be removed with ease at 
the next sitting. 

PROLAPSE OF THE RECTUM 

In prolapse of the rectum of the second degree, where the pro- 
lapse only involves one half of the circumference of the bowel, 
local anesthesia may be employed, and the prolapsed portion ligated 
off in sections. As a general proposition, however, the author does 
not advise its use. Operations for prolapse have been done by some 
proctologists under local anesthesia ; but the technic is rather crude, 
and the same satisfactory results cannot be obtained in this hurried 
method, as are possible under general anesthesia. In prolapse of 
the third degree (Fig. 185), local anesthesia is obviously contrain- 
dicated, as the most successful operation for the reduction of com- 
plete prolapse is best accomplished by means of an abdominal opera- 
tion. 

REMOVAL OF CONCRETIONS 

The removal of concretions from the rectum or sigmoid, which 
are larger than one inch and a half in circumference, should not 
be attempted under local anesthesia, but can be done very nicely 
under the anesthesia produced by the administration of nitrous 
oxid and oxygen. While almost any case of fecal impaction can 
be relieved under local anesthesia, as has been pointed out in 
Chapter V, there are some cases in which the procedure fatigues 
the patient so much that the administration of a general anesthetic 
may be necessary in order to successfully complete the operation. 

FISTULA COMMUNICATING WITH OTHER ORGANS 

Operations for fistula communicating between the rectum and other 
adjacent organs should never be attempted under local anesthesia, 
neither should the extensive use of the thermocautery be attempted 
unless the patient is under profound anesthesia, if used at all. Be- 
fore attempting any operation for relief of any pathological condi- 
tion discovered in the anus or rectum, the absence of any other dis- 



332 



DISEASES OF THE RECTUM 



eased condition higher up in the rectum should first be demonstrated 
by careful proctoscopic and sigmoidoscope examinations. 

Many procedures cautioned against in this chapter are performed 
by the author in his hospital service under local anesthesia with sig- 
nal succcess. There is no limit to the extent of the field of local 
anesthesia in proctology but the skill of the individual. Until, how- 
ever, one has by long experience become an adept in its use, caution 
and conservation should be the watchwords of everyone employing 
local anesthesia, no matter how simple the case may seem to be. 



CHAPTER XVII 

THE FECES AND THEIR CLINICAL EXAMINATION 

It is surprising that in the study of intestinal diseases so little at- 
tention has been given to the careful study of the stool. The study of 
the feces bears the same relation to the study of intestinal derange- 
ments as the examination of the urine to the diagnosis of renal dis- 
eases. 

In order to make this chapter of value to the general practitioner 
the author has, as far as possible, included only the practical part of 
coprology, omitting those procedures that are of no particular bene- 
fit to clinical medicine and those requiring special laboratory train- 
ing. 

Under the term feces are comprised all those substances which, be- 
ing formed from the food in the process of digestion, and mixed with 
the residue of the secretions of the alimentary canal, are finally ex- 
pelled by the rectum. 

GENERAL CHARACTERISTICS OF FECES 

Number of Stools. — The number of stools in 24 hours varies 
greatly in different persons, who are apparently in good health. One 
may have two or three bowel movements in 24 hours, while another 
may have one in 48 hours ; so it is important to ascertain the habitual 
number of stools, in every individual. There are rare instances in 
which one stool occurs only in two weeks to four months. It is better, 
however, to take the general condition of the patient as a guide to the 
sufficiency of defecation. Some individuals will tolerate infrequent 
defecations, while others would suffer from copremia under the same 
conditions. 

Duration of Passage. — The question of the length of time required 
for the passage of food through the gastrointestinal canal is a matter 
of much clinical importance ; yet little attention has been paid to the 
subject. It is quite as important to know the period of passage as to 
know how often the patient has a stool. A patient may have one stool 

333 



334 DISEASES OF THE RECTUM 

a day and yet have latent constipation, which gives rise to toxic symp- 
toms. Whether latent constipation is present can only be determined 
by estimating the period of passage. In diarrhea, by estimating the 
period of passage, it is possible to come to an approximate idea of the 
seat of the disturbance producing the diarrhea. If the period of pas- 
sage is nearly normal, the trouble lies in the lower or middle portion of 
the large intestine, and peristalsis is probably not increased in the 
small intestine. Chronic colitis, with several watery movements a day, 
may be accompanied by a normal passage. The period is decidedly 
shortened if the inflammation is in the ascending colon or small bowel. 
Strauss used a test-diet of 100 grams of lean meat and found the nor- 
mal period to be 10 to 20 hours. This was increased in cases of con- 
stipation to as high as 60 hours. Maurel, using a pure milk diet, 
gives the normal period 36 to 48 hours. In disease the shortest period 
was 4 hours, and in such cases the bilirubin is found unaltered. The 
period of passage is very easily marked by giving a capsule of car- 
mine or charcoal with the meal and watching for the first red or 
black stool. 

Amount. — The amount varies in different individuals, depending 
upon the character of the diet and the condition of the digestive or- 
gans. The quantity is increased by a diet rich in vegetables and 
starchy foods, and diminished by one rich in animal food. 

The stool consists of the indigestible portion of the diet, the part of 
the diet undigested, bacteria, and the secretions of the intestines and 
their associate glands. Cetti, who fasted 10 days, passed about 22 
grams of stool on the average a day. The normal amount varies be- 
tween 100 and 200 grams in 24 hours. 

Consistency and Form. — The consistency of the stool depends 
chiefly upon the amount of water it contains, though there may be 
soft, thin stools due to abnormal amounts of fat or mucus. Increase 
of the fluid in the stools may be due to deficient absorption, or to ex- 
udate or transudate from the mucous membrane. Increased peri- 
stalsis may cause watery stools through failure of absorption, while 
prolonged retention in the colon or rectum may result in hard, scyb- 
alous masses due to excessive absorption of water. 

Odor. — The odor of the feces is, to a large extent, due to the pres- 
ence of indol, skatol, sulphuretted hydrogen, and methane. 

Color of Stools. — The color of the feces varies according to the 



EXAMINATION OF FECES 



335 



nature of the food ingested. The normal color is dark brown. A 
diet consisting largely of meat gives an intensely brown stool, while 
a vegetable diet gives a more yellowish shade to the feces. A stool 
that has been exposed to the air is darker on the outside than on the 
interior, owing to the process of oxidation. The presence of undi- 
gested fats gives a yellowish shade to the stool. If much blood is 
present the stool may be black or have a tarry appearance. Huckle- 
berries and red wine produce a dark stool; chocolate and cocoa, gray; 
iron, manganese, and bismuth preparations, a dark or black stool, 
owing to the formation of the oxids of these metals (Fig. 203). 
Calomel causes a greenish stool (biliverdin) ; santonin, rhubarb, and 
senna produce a yellow color. 















Fig. 203. — Sulphid of bismuth crystals from the stools. (Eyepiece III, objective 8A, 
Reichert.). — Von Jaksch and Cagney: Clinical Diagnosis. 

Macroscopic Elements. — These are derived either from the food 
or from the intestinal apparatus itself. It is possible to find stones, 
cherry pits, grape seeds, skins of various berries or apples, pears, etc., 
pieces of connective tissue, grains of corn — in fact, almost any part 
of the food if insufficiently masticated. The presence of casein in 
the stools of infants appears as small whitish lumps and can, as a rule, 
be easily recognized. Foreign bodies of almost every description, 
which are not too large to swallow, may be found in the stools, espe- 
cially in the stools of children and of the hysterical or of the insane ; 
one may find buttons, coins, pins, false teeth, hair balls, etc. 

Microscopic Elements. — Microscopically, may be seen indigestible 



336 



DISEASES OF THE RECTUM 



and undigested portions of the food, as well as substances thrown off 
by the mucous membrane of the intestines. Thus, starch granules 
and remnants of chlorophyll, muscle-fibers, elastic-tissue fibers, con- 
nective-tissue fibers, flakes of casein, white blood-corpuscles, triple 
phosphate crystals, micro-organisms, etc., may be seen (Fig. 204). 

CLINICAL EXAMINATION OF THE STOOLS 

In order to make the clinical examination of the stools of benefit 
and satisfactory, we must have a standard for comparison. Schmidt, 
of Dresden, has formulated a diet to meet this requirement, and it, 




Fig 204. — Collective view of the feces. (Eyepiece III, objective 8A, Reichert.) a, muscle- 
fibers; b, connective tissue; c, epithelium; d, white blood-corpuscles; e, spiral cells; f-i, 
various vegetable cells; k, triple phosphate crystals in a mass of various micro-organisms; 
1, diatoms. — Von Jaksch and Cagney : Clinical Diagnosis. 

or some modification, is now in general use by those following this 
line of work. There are two conditions for the satisfactory clinical 
examination of the feces : 

1. A knowledge of what a normal stool should be under a certain 
diet. 

2. The methods of examination must be as simple as possible. 
The test-diet. — The requirements are : 

(a) That is must be nutritious enough to furnish calories sufficient 
for the body's need. 

(b) It must consist of such articles of food as can be obtained in 
any household. 

(c) It must contain a constant amount of certain articles, so that 
variation in digestion and absorption can be detected in the stool. 

Schmidt's diet is as follows: 1.5 liters of milk, 100 grams of zwie- 
back, 2 eggs, 50 grams butter, 125 grams very rare or raw beef, 190 



EXAMINATION OF FECES 337 

grams potato, and gruel from 60 grams oatmeal and 20 grams sugar. 

This may be divided as follows : 

Breakfast. — Two eggs, half liter or two glasses of milk, one third 
the amount of zwieback and butter, or two slices of well-toasted 
bread, with butter, and the oatmeal and sugar. 

Dinner. — The steak and potatoes, one-third zwieback and butter, 
and two glasses of milk. 

Supper. — Two glasses of milk, and the remainder of toast, or zwie- 
back and butter. 

The amounts of each article should be measured or weighed ac- 
curately, and the beginning of the test-diet marked by giving a cap- 
sule containing carmine or charcoal, preferably the latter, because 
carmine would interfere with the color reaction in case an examina- 
tion is made for blood in the stool. This diet should be given for 
several days. The first black stool will denote the length of time re- 
quired for the passage of food through the gastrointestinal tract. 
The examination of the stool consists of the following steps : The con- 
sistency, color, and smell must be observed. Then a piece of formed 
stool the size of a walnut, or an equivalent amount of liquid feces, is 
rubbed up in a mortar with distilled water until it is quite smooth 
and liquid. Part of this is poured upon a glass plate or a Petri dish, 
put over a dark background, and examined in a good light. 

In normal digestion, very little should be seen by the naked eye 
except small brown points (oatmeal), and occasionally sago-like grains 
that look like mucus, but which the microscope shows to be grains 
of potato. 

Pathologically, there may be : 

1. Mucus in large or small flakes which is not affected by rubbing 
up in the mortar. The smaller the flakes, the harder they are to 
recognize. They appear as glassj^ translucent flakes often stained 
yellow by bile pigment. If at all doubtful, the microscopic examina- 
tion will clear it up. 

2. Pus, blood if considerable, can be easily detected, as can also 
parasites, stones, and foreign bodies. 

3. Remnants of muscle-fiber appear as small, reddish-brown threads, 
or small irregular lumps. AYhen they can be easily seen by the naked 
eye and are quite numerous, it shows impairment of intestinal di- 
gestion. 



338 DISEASES OF THE RECTUM 

4. Remnants of connective tissue and sinew from the beef-steak 
can be detected from the mucus by their toughness and whitish-yel- 
low color. If in doubt, a piece may be put on a slide with a drop 
of acetic acid and examined with the microscope. The connective tis- 
sue loses its fibrous structure, while the mucus becomes more thread- 
like. Small pieces of connective tissue can be found in normal stools, 
but when they are numerous and large their presence indicates 
the impairment of gastric digestion. 

5. Remnants of potato look like grains of boiled tapioca and may be 
confused with mucus. Any doubt of the nature of the particles can 
be cleared up by the microscope. 

6. Large crystals of acid phosphate of ammonium and magnesium 
occur in foul stools, and can be easily recognized by their shape and 
chemical reaction (solubility in all acids). 

MICROSCOPIC EXAMINATION 

For microscopic examination, prepare three slides from the liquid 
feces. 

The first slide — a drop of the material to be examined under high 
and low power. 

The second slide — mix a drop of the material with a drop of acetic 
acid (U. S. P.), heating it to the boiling point, then put on the cover- 
glass. 

The third slide — a drop of the material with a drop of weak 
Lugol solution (iodin 1, KI 2, water 50). 

Normal stool. — Slide one : 

(a) Single, small muscle-fibers, colored yellow, usually with a cross 
striation (Fig. 205). 

(b) Small and large yellow crystals of salts of fatty acids. 

(c) Colorless particles of soap (gray). 

(d) Single potato cells. 

(e) Particles of oatmeal. 

In the second slide a general idea of the fat content of the stool 
can be obtained. Upon cooling, small flakes of fat acids can be seen. 
The large crystals of salts of fatty acids and the soap are broken up 
by the acetic acid, and fat acids are liberated. If the slide is heated 
again and examined while hot, the fat acids will be seen to run to- 
gether in drops, which, as the slide cools, break suddenly apart. 



EXAMINATION OF FECES 



339 



In the third slide, there should be violet-blue grains in some of the 
potato cells, and small, single bine points, probably fungi spores. 
Pathologically there may be. — Slide 1 : 

(a) Muscle-fiber in excess, perhaps with yellow nuclei. 

(b) Neutral fat drops or fatty acids in crystals. 

(c) An excess of potato cells with more or less well-preserved con- 
tents. 

(d) Parasite eggs, mucus, connective tissue, pus, etc. 
Slide 2 : Fat acid flakes in excess. 

Slide 3 : Blue starch grains in potato cells or free oatmeal cells, 
fungus spores or mycelia. 




Fig. 205. — Muscle remnants in feces. (Leitz objective VII.) a, large; b, medium; and c, 
small fragments. — From Schmidt and Strassburger. 



CHEMICAL EXAMINATION 

Reaction. — The reaction of the stool is hard to get with litmus 
paper, but can be easily obtained by dropping a little softened fecal 
matter into 5 or 10 cubic centimeters of a weak, watery solution of 
litmus, shaking it and noticing the change. It is well to use another 
test-tube with the litmus solution only, as a control. The test should 
always be made with freshly passed feces, inasmuch as the reaction 
of the feces may change upon standing. 

Sublimate Test. — Consists of taking a few cubic centimeters of the 
liquid feces and mixing it with an equal amount of 25 per cent watery 
solution of mercuric chlorid. A normal stool will turn a pinkish- 
red, indicating the presence of hydro-bilirubin, which will be more 
intense the fresher the material. A green color, even if it is detected 
microscopically, is pathologic and indicates unchanged bile pigment. 



340 



DISEASES OF THE RECTUM 



Fermentation Test. — About 5 grams of freshly formed feces are 
taken, or an equivalent amount of thinner material. Steele's fermen- 
tation apparatus, a modification of Strassburger 's, is used. It is con- 
structed of perforated rubber corks, bent glass-tubing, and two test- 
tubes of 30 cubic centimeters capacity (Fig. 206). A small glass tube 
beam runs up to the top of the test-tube (C) to allow for the escape 
of air. 




Fig. 206. — Steele's modification of Strassburger's fermentation apparatus. It is con- 
structed of perforated rubber corks, bent-glass tubing, and two test-tubes, each of 30 cubic 
centimeters capacity. The small glass tube D runs up to the top of the test tube C, to 
allow for the escape of air, instead of the test-tube being perforated, as in Strassburger's 
apparatus. — Progressive Medicine, December, 1905. 

The stool is rubbed up with sterile water and poured into the main 
bottle (A). 

This is filled with sterile water; tube B is filled with water and 
fitted in place, and tube C is then fitted on empty. The reaction is 



EXAMINATION OF FECES 



341 



carefully noted before the test is started. The apparatus is then 
stood in a warm place for 24 hours, best in an incubator at 37° C. 
If gas forms by fermentation in A, it will rise into B, and the amount 
will be indicated by the water displaced into C. Normally, the fer- 
mentation test should show practically no gas, and the original reac- 
tion should be unchanged for 24 hours. If more than one-third of the 

Fig. 207. — Mucus shreds. — From Schmidt and Strassburger. 




Fig. 208. — Mucus shreds after the addition of acetic acid. — Hensel, Weil, and Jelliffe: 
Urine and Feces in Diagnosis. 



tube C is filled, it is pathologic. If, then, the reaction is decidedly 
more acid, it is a carbohydrate fermentation; if alkaline and with a 
foul smell, it is a fermentation of albumins. 

Estimation of Lost Albumin Residue. — A qualitative test may be 
made as follows : 



342 DISEASES OF THE RECTUM 

A softened portion of the stool is filtered; the filtrate shaken with 
silicon and refiltered; then it is saturated with acetic acid to bring 
down the nucleo-proteids ; after filtration a drop of f errocyanid solu- 
tion is added. A decided precipitate indicates albumin. 

It was formerly thought that a positive test shows a diminution of 
albumin digestion, but the work of recent investigators would indi- 
cate that this is not the case. Under pathologic conditions, the nucleo- 
proteids may be decidedly increased, although their presence is not 
characteristic of any particular disease. Other forms of albumin are 
rarely found in the feces, even after the ingestion of excessive amounts. 
The occurrence of albumin in the feces of adults is almost always 
associated with diarrhea, and usually with an excessive formation of 
mucus. It usually is serum-albumin, much less frequently albumoses. 
Such ■ ' lost albumin ' ' in the stools indicates severe anatomical changes 
in the bowel, but usually not disturbance of absorption. The albumin 
under these circumstances comes from the intestinal wall, and some- 
times a part of it may be digested by the intestinal ferments into al- 
bumoses. 

CLINICAL SIGNIFICANCE OF TEST 

Mucus. — There are two conditions in which the presence of mucus 
in the stools has no significance: when hard, dry masses of feces 
are covered with thin mucus, without evidence of rectal inflamma- 
tion; and when it is discharged in casts, the so-called mucous 
colic. Otherwise it indicates inflammation of the intestinal mu- 
cous membrane. If it is densely impregnated with bacteria, food 
remnants, and detritus, the origin of the inflammation is probably 
high up in the intestine (Figs. 207, 208). 

Bilirubin. — Bilirubin discoloration affords no certain evidence of 
inflammation of the small intestine, but the presence of bilirubin 
granules and crystals in a cellular arrangement is suggestive. 

Semidigested Cells. — The presence of semidigested cells or of their 
nuclei indicates an origin high up in the bowel. 

Hyaline Cells. — The presence of hyaline cells favors the assump- 
tion that an inflammation of the colon exists. 

Bile Pigment. — A green color of part or all of a stool, by the sub- 
limate test, is pathologic, except in children. It means a too short 
period of passage through the intestine, and that time for a normal 



EXAMINATION OF FECES 



343 



reduction process of the bilirubin into hydro-bilirubin was lacking. 
A normal fresh stool will give a pink color with mercuric chlorid. 
If a color reaction of any kind is absent, it indicates a very fat 
stool, or an absence of bile in the intestine (Figs. 209, 210). 

The assumption of the temporary stoppage of the bile does not 
account for all of the cases of colorless feces which do not darken 
on exposure. The pathologic conditions in which colorless feces 




Fig. 209. — Hematoidin crystals from acholic stools. (Eyepiece III, objective 8A, Reichert.) 

— Von Jaksch and Cagney. 




Fig. 210. — Acholic stools. (Eyepiece III, objective 1-15, oil immersion, 
mirror, narrow diaphragm.) — Von Jaksch and Cagney. 



Reichert, Abbe's 



without jaundice may occur comprise defective supply of bile to 
the duodenum, intestinal catarrh, tuberculous abdominal disease, 
malignant disease of the intestine, septic diseases (especially those 
which affect the abdomen), chlorosis, and leucemia. 

Fat. — It will need a little practice to tell, by the use of the diet, 
whether there is an increase of fat in the stool. As the normal 
amount of fat in the feces varies between wide limits, only a con- 
siderable excess of fat can be detected. 



344 DISEASES OF THE RECTUM 

Remnants of Meat. — Normally there should be only microscopic 
particles of connective tissue and muscle-fiber. An excess of either 
is often visible to the naked eye, but need not be macroscopic to 
be pathologic. 

Excess of Connective Tissue.— This indicates insufficient gastric 
digestion, because such fibrous tissue is only digested by the gastric 
juice. The meat should be rare, to give this test its full value. 
If motility is increased, there may be an excess of this in hy- 
peracidity. 

Excess of Undigested Muscle-Fiber. — This indicates intestinal in- 
digestion and probably means trouble in the upper part of the 
small intestine ; but whether the trouble is in the trypsin of the 
pancreatic secretion, or the activating principle (enterokinase) of 
the intestinal juice, or in increased peristalsis, we can only judge 
from other symptoms. When the gastric juice fails to digest away 
the framework of the muscle-fiber, giving the intestinal juices no 
chance to do their work, connective tissue and muscle-fiber are often 
found. This occurs often in acute gastric catarrh. 

Pathologic Carbohydrate Fermentation. — This means poor starch 
digestion and indicates, as a rule, disturbance in the small intestine, 
and usually is due to insufficiency of the succus entericus. 

Pathologic Albumin Fermentation. — This means a large residue 
of albumin in the feces and indicates usually some anatomical change 
in the mucous membrane of the small intestine. 

Pus. — This can be rarely recognized in the stool unless it comes 
from the lower part of the large bowel; if it comes from high up 
in the intestine, it is rapidly changed. 

Blood in the Stools. — The presence of blood in such quantities as 
to be visible is considered in Chapter II, so I will only consider the 
so-called occult blood in the stools. The presence of occult bleed- 
ing from the gastrointestinal tract is a symptom of much im- 
portance, provided various sources of error can be eliminated. It 
has the same clinical significance as visible hemorrhage, and its 
presence is of decided diagnostic value, chiefly in the detection of 
gastric or duodenal ulcer, or gastrointestinal cancer, because it oc- 
curs with considerably more regularity and frequency in these af- 
fections than in any other condition of the gastrointestinal tract. 



EXAMINATION OF FECES 345 

The value of this sign depends entirely upon the care with 
which the various sources of error are eliminated, and if the re- 
action is positive, will be of value in the diagnosis of cancer or 
ulcer of the gastrointestinal tract only when sources of bleeding 
that have no significance are excluded. On the other hand, after 
repeated examinations, if occult blood is not found, then cancer 
or ulcer can be excluded. Since the test is very sensitive (very 
small amounts can be detected), the chance for error in deter- 
mining the origin of the hemorrhage is greater than in large and 
visible hemorrhages. Observations have shown a positive reaction 
in the feces on the ingestion of 0.5 grams of blood. It is possible 
to exclude the source of the blood when in the lower bowel by 
the use of the proctoscope, etc. Tuberculous ulcer, typhoid fever, 
hemorrhoids, fissure, and purpura can be easily excluded; other 
conditions, however — e. g., cirrhosis of the liver with slight symp- 
toms — may be the cause of error. Eed beets, carmine, swallowed 
blood from any cause, hemoptysis, epistaxis, menstruation, cirrhosis 
of the liver, purpura, benign stenosis with stagnation, tuberculous 
enteritis, cancer of the gastrointestinal tract, gastric or duodenal 
ulcer, typhoid ulcer, hemophilia, hemorrhoids, ulcer, fissure, and 
fistula of the anus and rectum are a partial list of conditions which 
may give a positive reaction with the various tests. 

When testing for occult blood it is best to have the patient on 
a diet free from meats and meat juices and to give a good-sized 
capsule of charcoal; the first black stool will mark the feces fol- 
lowing the meat-free diet. 

A number of different tests are used for the detection of occult 
blood; probably the Weber test, with its various modifications, is 
the one most employed. It is well, however, to use a control test, 
preferably Klunge's aloin test. If both tests give a positive reac- 
tion, there is no doubt but that there is blood in the stools. The 
latter is not liable to be obscured by bile pigments or chlorophyll, 
in the ethereal extract, and is extremely delicate. 

Weber's Test. — Take 2 or 3 grams of feces, mix thoroughly with 20 cubic 
centimeters of water ; extract with 20 cubic centimeters of ether to remove fats. 
Then use one-third the volume of acetic acid and shake well; add 10 cubic centi- 
meters of ether and shake well. If ether does not come to the top soon, add a 
few drops of absolute alcohol. To 2 cubic centimeters of the ethereal extract, add 
10 drops freshly prepared tincture of guaiac and 10 to 20 drops of ozonized tur- 



346 DISEASES OF THE RECTUM 

pentine. Care must be taken that all utensils are absolutely clean and free from 
water. If blood is present, an intense blue color appears, gradually assuming a 
reddish-violet tint. 

Klunge's Aloin Test. — Take a small quantity of aloin, mix with 3 to 5 
cubic centimeters of 70 per cent alcohol. Four to five cubic centimeters of acetic 
acid ethereal extract is tried with 20 to 30 drops of ozonized turpentine and 10 to 
15 drops of the aloin solution. If blood is present, a bright-red color appears, 
which turns to a cherry-red on standing. If blood is not present, a yellow color 
remains for an hour or two, then becomes pink. It may take 15 or 20 minutes to 
get a positive reaction. 

Holland's Modification of Weber's Test. — Instead of using ozonized tur- 
pentine, Holland uses sodium perborate (Shering) in tablet form; a few drops of 
the acetic acid-ether mixture is placed upon a small piece of tablet of perborate 
of sodium, and a drop or two of the tincture of guaiac is cautiously brought into 
contact with it, preferably on a white plate. If blood is present, the perborate 
turns blue in a few minutes and remains blue until the drying of the tincture of 




Fig. 211. — Gallstones. 

guaiac leaves a yellow residue which changes the blue to green. If the proportion 
of blood is small, the perborate turns a pale blue, which turns green as the 
guaiac dries. 

Benzidin Test. — A little benzidin and about 2 cubic centimeters glacial acetic 
acid are shaken up together and set aside for the benzidin to dissolve. A piece 
of feces the size of a bean is stirred into a test-tube about one-fifth full of water; 
the tube is plugged with cotton, and the suspension of fecal mater is heated to a 
boiling point over a flame. About 10 or 12 drops of the concentrated benzidin 
solution are poured into another test-tube, from 2 to 2.5 cubic centimeters of 
a 3 per cent solution of peroxid of hydrogen added. One or two drops of the 
boiled suspension of feces are then added to this mixture. If blood is present in 
the feces, this brownish fluid turns green or blue ; the more blood the more the test 
inclines to blue. The color reaction occurs within two minutes in the presence 
of blood and turns to a dirty-purple in five to fifteen minutes. If there is no 
blood present, the dirty-brown color remains unaltered. 

Gallstones. — In cases of colicky abdominal pain, the feces should 
always be examined for biliary concretions. The best way to search 
for gallstones is to put the feces in a fine sieve and wash the stool 



EXAMINATION OF FECES 347 

with running water from a faucet, if possible. The concretions 
vary in size from as small as the head of a pin to the size of a 
pigeon's egg. They may be seen as small crumbling masses, as 
hard stones presenting an irregular contour, or as smooth facets 
(Fig. 211). The larger stones are not passed by the bowel unless 
perforation has occurred into the intestine. The composition of 
the calculi varies. Some are composed of cholesterin; some of in- 
spissated bile; and others of calcareous salts. Those composed of 
cholesterin are the most common and are somewhat soft, and white, 
grayish, bluish, or greenish in color. I think that the consensus 
of opinion inclines to the belief that the nucleus of the majority of 
gallstones is clumps of bacteria, either colon or typhoid bacilli, al- 
though it may be composed of earthy sulphates or phosphates. Cal- 
culi which consist largely of biliary pigments are brown in color, 
hard, and heavier than water; those composed of calcareous salts 
are generally irregular and rough. 

Intestinal concretions, or enteroliths, are rare. At times their 
nucleus consists of some foreign body like a fruit seed, upon which 
calcium and magnesium salts have become deposited. 

Intestinal sand is hard, gritty, pale brown to black in color, readily 
sinks in water, and is usually composed of the salts of calcium 
magnesium and ammonium. Sometimes silica is present. 

ANIMAL PARASITES 

Protozoa. — Of the protozoa, the amebse (Chapter XIII) are the 
most important in the etiology of intestinal disease. It is possible 
to find amebae in the stools of perfectly normal individuals, and they 
increase in number as the stools become more alkaline in reaction. 

Amoeba Coli. — In certain forms of dysentery the Amceoce coli 
occur in the stool in enormous numbers, chiefly embedded in the 
mucus. They are also found on pathologic examination in the 
ulcers in the intestines. In examining, the stool must be fresh, 
as the amebae very rapidly die off in a stool that has been pre- 
served but a few hours. A particle of mucus, preferably blood 
streaked, is taken from a fresh stool and placed on a chemically 
clean slide, better, a warm stage. In adjusting the cover-glass, 
a horsehair or some similar object should be placed between it 



348 



DISEASES OF THE RECTUM 



and the slide, in order not to crush the organisms or interfere 
with their locomotion. Examine with a low-power microscope. 
They are from 10 to 50 micromillimeters in size. When at rest, 
their outline is, as a rule, circular or ovoid; when in motion, 
they present one or more arm-like prolongations, "the pseudo- 
podia." The protoplasm can be differentiated into a translucent, 
homogenous ectosarc or mobile portion and a granular endosarc 




Fig. 212. — Amoeba coli. — Simon: Clinical Diagnosis. 




Fig. 213. — Balantidium coli. — 1 and 2, stages of division; 3, conjugation. — After Leuckart, 
Progressive Medicine, December, 1905. 



containing the nucleus, vacuoles, and granules (Fig. 212). As 
a rule, one or two vacuoles are present, the edges of which are 
not infrequently surrounded by fine, dark granules. 

Balantidium Coli. — Another form of protozoon, that is an etio- 
logic factor in certain forms of dysentery, is the Balantidium 
coli. This organsim is a harmless inhabitant of the colon of the 



EXAMINATION OF FECES 349 

pig, and it is supposed, is transferred to human beings through 
sausages (Fig. 213). The parasite is of oval shape, 60 to 100 
microns long and 50 to 70 broad, and is covered with cilia that 
are in rapid motion when the organism is alive. Ectosarc and 
endosarc are sharply differentiated. The endosarc is granular 
and contains a kidney-shaped nucleus, generally two contractile 
vacuoles, and granular detritus. Motion is so rapid that it can- 
not be followed under the microscope. The protozoon dies very 
quickly and undergoes fragmentation. 

There are other forms of protozoa, but their role in the etiology 
of intestinal diseases is not definitely settled. 

Worms. — The diagnosis of helminthiasis from the stools may be 
very easy, or it may require considerable painstaking research. If 
segments of the tenia pass in the stools, the diagnosis is quite 
evident. In other cases, a diagnosis can only be made by finding 
the ova in the feces. To examine for the ova, take a small amount 
of feces from different parts of the stool, dilute it very much with 
sterile water, and centrifuge repeatedly. After each centrifugaliza- 
tion, the supernatant dirty water is thrown away, and fresh water is 
added, the whole shaken up and again placed in the centrifuge, 
this to be repeated five or six times. In this way all bacteria, free 
coloring matter, light vegetable matter, etc., are removed, and 
only heavier particles, including any ova that may be present, will 
remain and can be easily and satisfactorily examined under a low 
power of the microscope. There is left no obscuring cloud of 
bacteria or fine granular debris, but instead, each ovum, or muscle- 
fiber, or crystal stands out sharply and clearly. 

Nematodes. — Nematodes are round worms. Those found in the 
human being are: 

1. Ascaris lumbricoides is the most common parasite of the human 
intestinal canal. They are found chiefly in the small intestines 
but may find their way into the stomach, the bile passages, or out 
at the anus. Clumps of them have been known to cause intestinal 
obstruction. 

The worm is cylindrical, the male being from 10 to 25 centi- 
meters in length, the female from 25 to 40 centimeters. The 
head consists of three projections or lips, which are provided 
with suckers and fine teeth. The tail end of the male is rolled 



350 



DISEASES OF THE RECTUM 



up on its central surface like a hook and is provided with papillae. 
The genital aperture of the female is situated directly behind 
the anterior third of the body. The eggs are yellowish-brown in 
color, almost round, and measure 0.06 millimeters by 0.07 milli- 
meters in size. They are surrounded by an irregular albuminous 
envelope, which is covered by a tough shell; the contents are 
coarsely granular (Fig. 214). 

2. Oxyuris vermicularis (common threadworm, seatworm, pin- 
worm, etc.) is a very frequent parasite, especially in young chil- 




Fig. 214. — Ascaris lumbricoides. a, the worm; b, the head; c, egg; a, half natural 
size; b, slightly magnified; c, eyepiece 1, objective 8A Reichert. — Von Jaksch and Cagney: 
Clinical Diagnosis. 



dren, often passing from the anus into the vulva in female chil- 
dren and setting up considerable irritation in the vagina. The male 
is 4 millimeters, the female 10 millimeters, long. At the head three 
lip-like projections with lateral cuticular thickenings may be seen. 
The tail of the male is provided with six pairs of papilla?, and the 
female with two uteri. The eggs are 0.05 by 0.02 to 0.03 millimeters 
in size, and covered with a membrane showing a double or triple 
contour. In the interior, which is coarsely granular, the embryo 
is contained. The ova do not occur in the feces (Figs. 215, 216). 



EXAMINATION OF FECES 



351 



Ankylostoma duodenale, or Dochmius duodenalis, or Strongylus 
duodenalis is generally described in America as Uncinaria. It was 
formerly supposed that this parasite was found only in the Old 
World and only brought into this country, but it has been demon- 
strated that there are many endemic cases in our Southern states. 




Fig. 215. — Oxyuris vermicularis. a, sexually mature female; b, female filled with eggs; 
c, male. Magnification, X10. — After Heller, from Zeigler. 

There are certain differences between the American and Old 
World parasite. 

Stiles 1 gives the following description: 

Uncinaria duodenalis. — The Old World hookworm. Body cylindrical, some- 
what attenuated anteriorly; buccal cavity with two pairs of ventral teeth curved 



lBulletin No. 10 Hygienic Labratory, U. S. Public Health and Marine Hospital Service. 



352 



DISEASES OF THE RECTUM 



like hooks, and one pair of dorsal teeth directed backward; dorsal rib not project- 
ing into cavity. Male 8 to 11 millimeters long, caudal bursae with dorso-median 
lobe and prominent lateral lobes united by a ventral and slender. Female, 10 to 
11 millimeters long; vulva at or near posterior third of body. Eggs ellipsoid, 52 
to 60 micromillimeters by 32 micromillimeters, laid in segmentation. Development 
direct without intervening host (Fig. 217). 

Uncinaria americana. — The New World hookworm of man: Body cylindrical, 
somewhat attenuated anteriorly; buccal capsule with a dorsal pair of prominent 
semilunar plates or lips and a ventral pair of slightly developed lips of same na- 
ture; dorsal conical median tooth projects prominently into buccal cavity. Male 
7 millimeters long, caudal bursae with short dorso-median lobe, which often ap- 
pears as if it were divided into two lobes, and with prominent lateral lobes united 
ventrally by an indistinct ventral lobe; common base of the dorsal and dorso- 
lateral rays very short; dorsal ray divided to its base, its two branches being 





Fig. 



216. — Oxyuris vermicularis. la, male; lb, female, natural size; 2, magnified. — Hensel, 
Weil, and Jelliffe: Urine and Feces in Diagnosis. 



widely divergent, and their tips being bipartite; spicules long and slender. Fe- 
male 9 to 11 millimeters long; vulva in anterior half of body but near equator. 
Eggs ellipsoid, 64 to 76 micromillimeters long by 36 to 40 micromillimeters broad, 
in some cases partially segmented in utero; in others containing a fully developed 
embryo oviposited. 

The eggs of the American species are much larger than those 
of the Old World species. The eggs have a transparent shell 
with a linear contour and are often found in enormous quan- 
tities in the feces. A rather peculiar fact is that the ova of un- 
cinaria, although sticking closely to the glass slide, do not seem 
to adhere to any of the other constituents of the stool. When 
a drop of washed sediment feces is allowed to remain on the 



EXAMINATION OF FECES 



353 



slide for a few minutes and then gently immersed in water and 
examined microscopically, the eggs are found adhering to the 
slide, and all else has been washed away. In suspected cases 
where the diagnosis is difficult, a full dose of thymol may make it 
clear, causing the appearance in the stool of the parasite, which 
appears as a thread-like body, a half to three quarters of an inch 
long, grayish-red in color. Its habitat is the jejunum and duodenum. 
Infection takes place through contaminated drinking water. 

For persons who are not in a position to make a microscopic 
examination, the blotting-paper test will be found very useful. 



b a 




Fig. 217. — Anklostomum duodenale. — Von Jaksch and Cagney. 

a. Male (natural size). 

b. Female (natural size). 

c. Male (magnified). 

d. Female ("magnified). 

e. Head (eyepiece II, objective C, Zeiss). 

f. Eggs. 



To make the test use only fresh feces. Place an ounce or more 
of the stool on a piece of white blotting paper, allowing it to 
remain for 20 to 60 minutes; remove the feces, and examine the 
color of the stain. In about 75 per cent of the cases of medium 
or severe uncinariasis, the stain is a reddish-broAvn, resembling 
somewhat a blood stain. In making this test on anemic patients, 
hemorrhoids must be excluded. 

Trichocephalus dispar, or "whip worm," frequent in most parts 
of the world, gets its name from being formed like a whip, the 



354 



DISEASES OF THE RECTUM 



lash end being the head end, while the tail end is very much 
thicker. The male measures 46 millimeters and the female 50 
millimeters in length. The eggs are brownish in color, 0.05 by 
0.06 millimeters in size, presenting a double-contoured shell with 
a depression at each end, closed by a lid. The contents are coarsely 
granular. Its habitat is in the cecum; the living worm is rarely 
found in the feces (Fig. 218). 

Trichina spiralis. — The male is 1.5 millimeters in length, and 
the female 3 millimeters. The male has four prominent papillae, 




Fig. 218. — Trichocephalus dispar. a, male; b, female; c, eggs; a, b, slightly magnified; c, 
eyepiece II, objective 8 A, Reichert. — Von Jaksch and Cagney. 



situated between the conical protuberances at the extremity. The 
female's sexual organs consist of a tubular ovary which is placed 
at the hinder part of the body and a tubular uterus with which 
the ovary communicates in front. Impregnation takes place in 
the intestine. The eggs develop into embryos while still in the 
uterus, and the newly born parasite almost immediately perforates 
the intestine and becomes imbedded in the muscles of its host. 
The mode of infection is through imperfectly cooked pork. Rarely 
is the parasite found in the stools. In suspected cases an anthel- 
mintic may cause the expulsion of the mature worm in the stool. 
Eosinophilia is a constant accompaniment of the presence of trichina 
(Fig. 219). 



EXAMINATION OF FECES 



355 




Fig. 219. — Trichinae. — Von Jaksch and Cagney. 

a. Male intestinal trichina (slightly magnified). 

b. Female intestinal trichina (slightly magnified). 

c. Trichina of muscle (eyepiece III, objective IV, Reichert). 




Fig. 220. — Anguillula stercoralis. — Von Jaksch and Cagney. 

a. Female. 

b. Male. 

c. Head (eyepiece II, objective 8A, Reichert). 



356 DISEASES OF THE RECTUM 

Anguillula intestinalis is 2.25 millimeters in length and 0.04 mil- 
limeters in thickness at its middle. It has a triangular mouth 
closed by three lips. Its vulva lies at the junction of the middle 
with the posterior third. Its habitat is the small intestines. The 
eggs resemble those of Ankylostoma duodenale, but are longer, more 
elliptical, and pointed at the poles. In recent stools the larvae 
alone can be seen. When sexually mature, it is known as Anguillula 
stercoralis; the body is round; it shows faint traces of transverse 
striation. The head is of the form of a blunt cone and sessile on 
the body, and is furnished with two lateral jaws, each bearing a 
pair of teeth. The male is 0.88 millimeters and the female 1.2 
millimeters long. Little is known concerning the manner of in- 
fection. Thayer reported the first case of infection by this worm 
in the U. S. (Fig. 220). 




Fig. 221. — Head of Taenia solium. — X45 (Leuckart). 

Cestode Worms. — Cestodes are popularly known as tapeworms. 
Externally they are long, flattened, segmented worms. The head 
is derived from the embryo contained in the flesh of the various 
domestic animals which are used as food. By budding it gives 
rise to all of the succeeding segments, which are morphologically 
the same, diminishing in size toward the head. 

Tcenia solium. — The tapeworm derived from pork may be two 
to three meters long. Head quadrilateral, about as large as a 
pinhead; it has four prominent suctorial discs, usually pigmented, 
and between them a rounded elevation which is surrounded with 
about 26 hooklets of different sizes, and is dark in color. This is 
succeeded by a delicate thread-like neck, about one inch in length 
and unjointed. The segments or proglottedes are short and rela- 
tively broad near the neck; the average length of the mature seg- 
ments is from 9 to 10 millimeters, and the breadth is 6 to 7 mil- 



EXAMINATION OF FECES 



357 



limeters. Each segment contains a uterus having five or seven 
branches. The ova are round, of a brownish color, and surrounded 
with a thick radially striated membrane; in their interior the hook- 
lets of the embryos can usually be made out (Fig. 221). 




H 


V 




ir 1 J A 


F1 


I; 




ru 


F 


r' 


£ ^ J 


r 






14 





Fig. 222. — Taenia saginata. — Simon: Clinical Diagnosis. 

a. Natural size. 

b. Head much enlarged. 

c. Ova much enlarged. 



Tarnia saginata {Medio cannulata) . — The most frequent tapeworm 
of Europe and America, infection taking place through measly 
beef. It is from 4 to 8 meters long. The head is surrounded with 



358 DISEASES OF THE RECTUM 

four large and usually black-pigmented suckers, but is not pro- 
vided with a rostellum, and is without a circle of hooklets. Seg- 
ments are rather thick and opaque, and each is provided with a 
very much-branched uterus which opens laterally. The ova are 
elliptical in form, of a brown color, and usually inclosed in a dis- 
tinct vitelline membrane. In the interior the embryos are seen 
embedded in a brown granular material (Fig. 222). 

Tcenia nana. — Occurs rarely in America, mostly in Southern 
Italy. It is 7 to 15 millimeters long. It occurs in large numbers, 
and is usually located in the lower part of the ileum. It has four 
suckers and a crown of hooklets. The segments are of a yellow- 
ish color and about four times as broad as long. The uterus is 
oblong and contains numerous ova, having two distinct mem- 





Fig. 223. — Head of Bothriocephalus latus. (Eyepiece III, objective IV, Reichert.) — Von 

Jaksch. and Cagney. 

a. Seen on edge. 

b. Seen on the flat. 

c. Proglottides. 

d. Eggs. 

branes. In the interior of the egg may be seen the embryo al- 
ready provided with five or six hooklets. Infection probably oc- 
curs from man to man. The parasites may be present in great 
numbers in the intestines, producing severe nervous symptoms, 
such as epileptic seizures, insensibility, mental derangements, etc. 
Bothriocephalus latus. — The longest of the human tapeworms has 
been found in the United States in only a few imported cases. 
The larvae have been found in various fishes. It is from five to 
eight meters long and tapers toAvard both extremities. The largest 
segments measure 35 millimeters in length, 10 to 12 millimeters 
in breadth. The head is ovoid, 25 millimeters long and 10 milli- 
meters broad, somewhat flattened, and provided in each lateral 
aspect with a groove-like sucking apparatus. The uterus is a 



EXAMINATION OF FECES 359 

slightly convoluted canal. The eggs are ovoid, 0.07 millimeters 
by 0.045 millimeters, and possess a thin brown capsule and open by a 
small lid at one end. This parasite may be the cause of severe 
anemia (Fig. 223). 

CHARACTER OF THE FECES IN CERTAIN INTESTINAL 

AFFECTIONS 

Acute Intestinal Catarrh. — This follows the ingestion of excessive 
quantities of normal food or tainted food, beer and certain poisons, 
acids or alkalies, arsenic, corrosive sublimate, etc., when taken in 
proper quantities; also find it in cholera nostras, typhoid fever, 
severe malaria, and in diseases of heart, lungs, and liver due to 
disturbance in circulation. The frequency of the stools depends 
largely upon the seat of the lesion, involvement of the large intestine, 
especially the transverse and descending colon, causing the bowels 
to move more frequently than trouble higher up. There may 
be from 10 to 15 passages a day. On the other hand, isolated 
catarrh of the small intestine may exist without giving rise to diar- 
rhea. The stools at first are semisolid, but rapidly become liquid, 
often foul-smelling, and associated with gas. The higher in the 
bowel the lesion, the more odor and gas. The color varies from a 
light to a dark brown. If the trouble exists in the small bowel 
only, the stools are firm, formed, and contain particles of hyaline 
mucus, visible only upon microscopic examination. They usually 
contain particles of undigested food. If the colon is affected, the 
stools are loose. Extensive involvement of the colon is usually 
accompanied by mucus in large quantities. 

Chronic Inflammation of the Intestine. — May follow an acute at- 
tack, or may follow some of the infectious diseases. Diarrhea usu- 
ally alternates with constipation. Rarer is continuous diarrhea or 
constipation. The feces present the same characteristics as the 
acute inflammations. 

Diphtheritic Enteritis.— Always diarrhea, often with tenesmus. 
Stools fluid, with occasional passage of formed feces. They consist 
mostly of pus, blood, and mucus, and some necrotic tissue may be 
found. 



360 



DISEASES OF THE RECTUM 



Mucomembranous Colitis. — No frequency in number of stools; 
may have constipation. Stools are composed largely of tough, 
leathery mucus, which may present casts of the bowel. This may 
be transparent or gray and semiopaque, or may be brown (from 
fecal matter), or red (blood). 

Cholera Nostras. — An infectious disease affecting both the stom- 
ach and bowels. The stools are first feculent, but soon become color- 
less and more and more watery, until they resemble the so-called 
" rice-water" stools of Asiatic cholera, and contain serum-albumin 
and mucin. 

Dysentery. — Stools are large and frequently composed of pus, 
mucus, and blood, fluid or semifluid; may find necrotic masses of 
mucous membrane. 

Amebic Dysentery. — Stools are frequent, fluid, and may contain 
large amounts of mucus, frequently stained with blood; reaction 
always alkaline. Microscopic examination of the fresh mucus shows 
epithelial and red blood-cells and the ameba. 

Carcinoma of the Small Intestine. — The stools of which have no 
distinctive feature. ' 

Carcinoma of the Rectum and Sigmoid. — This is taken up else- 
where in this volume (Chapter XVI). 



SYMPTOM INDEX 

A patient consults his physician, not with a diagnosis, or a 
disease, but with symptoms. The history of these symptoms plus 
the results of the physician's examination gives the evidence on 
which the diagnosis is founded. On the diagnosis, the treatment and 
the cure depend. 

In the clinical investigation of every case certain symptoms loom 
up more prominently than others. The most important, and vital, 
are, however, not always the most prominent in the patient's mind 
when he first consults his physician. 

This index of symptoms is presented with a view to more readily 
assist the practitioner in following down the list of symptoms in a 
given case to a diagnosis. 

For example : A patient gives the symptoms of pain of sudden 
onset, slight bright red hemorrhage with stool, acute constipation, 
and spasm of the sphincters. Look up the references under the 
headings of pain, hemorrhage, bright red; constipation, acute; and 
spasm, sphincteric. It will be found that fissure of the Anus, Acute, 
causes all of these symptoms, and examination will verify this 
diagnosis. 

Acne. (See Skin Diseases.) 
Altered Stools. (See Feces.) 
Anemia. (See Hemorrhage). Cancer, ulcerative colitis, proctitis, internal 

hemorrhoids, dysentery, polyposis. 
Ataxia, Sphincteric. Tabes dorsalis, spinal disease. 
Bad Breath. Constipation, colitis, cancer, impacted feces, obstipation. 
Backache, Sacral, hemorrhoids, intestinal cancer, colitis, proctitis, prolapse 

of rectum, constipation, obstipation, impacted feces, dysentery. 
Bleeding. (See Hemorrhage.) 

Black Stools. Cancer or Ulceration located in stomach or small intestine. 
Blood in Stools. (See Hemorrhage.) 
Boils. (See Skin Diseases.) Abscess, tegumentary. 
Casts. Mucous, colitis, dysentery. 

Colicky Pains. Colitis, proctitis, constipation, obstipation, intoxications, im- 
pacted feces, rectal stricture, cancer. 
Constipation. (See Chapter IV.) 
Cramps. (See colicky pains.) 

361 



362 DISEASES OF THE RECTUM 

Defecation, Diminished. (See Constipation.) 

increased. Diarrhea colitis, proctitis, cancer, ulcer, polyposis, foreign 
body in rectum, intoxications, hypercatharsis. 
Diarrhea. (See Defecation, increased.) 
Discharge. (See Hemorrhage, mucus, pus.) 

Disturbance, Menstrual. (See anemia — hemorrhage.) Eectal ulcer, obstipation, 
constipation, hemorrhoids internal. 
of sleep. Pruritus ani, intestinal parasites, anal fissure. 
of urination. Cancer, rectal ulcer and fissure, stricture, impacted feces. 
Elevations, abscess, hemorrhoids external, condyloma, cancer. 
Feces, blood in (Chapters II, XVI, XVII.) 

hard. Impaction, constipation, obstipation. 
impacted. (See Chapt. V.) 

liquid (diarrhea). Entero-colitis, proctitis, dysentery, intoxication, in- 
digestion, cancer, rectal ulcer, polyposis. 
mucous. (See Feces, liquid.) 
parasites in. (See Chapt. XVII.) 
pus in. Abscess, fistula, sinus, cancer, ulceration. 
ribbon. Stricture, hypertrophied rectal valves. 
Fever. Abscess, constipation, colitis, proctitis, impacted feces, intoxication, 

dysentery. 
Flatulence. Constipation, obstipation, colitis, dysentery, cancer, indigestion, 

intoxication. 
Gas. (see Flatulence.) 

Headache. Constipation, obstipation, impaction, intoxication. 
Hemorrhage. (Chapts. II, XVI, XVII.) 

bright colored. Cancer of anus, rectum or sigmoid, ulcer of same organs, 
polyposis, anal fissure stricture, internal hemorrhoids, traumatism, 
foreign body. 
dark colored. Oancer or ulcer of small intestine or stomach, retained rec- 
tal or colonic hemorrhage. 
Inflammation, (see Chapts. VII, VIII.) 
Involuntary Defecation. (See Loss of sphincteric control.) 
Itching. (See Chapt. VI.) 

Loss of Sphincteric Control. (See ataxia.) Tabes dorsalis, spinal diseases, 
traumatism, previous operative injury, anal ulceration, lacerated 
perineum. 
Mucus in stools. (Chapts. Ill, XII, XIII, XVII.) (See Feces Liquid) for- 
eign body. 
Nose picking of, in children. Intestinal parasites. (See Chapts. XVII.) 
Odor of Stools. (See Chapt. XVII.) 
Pain, (Chap. II.) 

acute cutting, lancinating. Fissure, anal ulcer, foreign body, acute. 
burning. Excoriations of circumanal skin. (See Chapts. VII, IX, XI, 

XII.) 
spasmodic. Fissure, anal ulcer, hypertrophied anal papillae. 
throbbing. Abscess, perirectal infection. (Chap. VIII.) 



SYMPTOM INDEX 363 

Pain, Absence of. Other symptoms being present, suspect cancer. 
Painful Passage. (See pain.) Any anal ulceration, fissure, internal hemor- 
rhoids, foreign body, enlarged prostate, abscess, stricture, cancer 
(low) impingement of diseased pelvic organs. 
Protrusions.— (Chapts. I, X, XI, XIV, XVI.) 

hard. Fibrous polyp, cancer, thrombotic hemorrhoids. 
nodular. Fibrous polyp, cancer. 
pedunculated. Polypi (all varieties). 

soft. Internal hemorrhoids, enlarged papillae, prolapse, myomatous polypi. 
reducible. All types of internal hemorrhoids, unless markedly thrombotic, 
polypi (with a snap) papillae, prolapse of all degrees, unless stran- 
gulated. 
non-reducible. Cancer, prolapse with atonic sphincters, interno-external 
hemorrhoids (chronic), acute thrombotic hemorrhoids (external and 
marginal. 
Pus. (See Discharge.) (Chapts. II, VII, VIII, IX.) Abscess, fistula, sinus, 

stricture, ulcer, fissure, cryptitis, foreign body, cancer. 
Restlessness at Night. Intestinal parasites, pruritus ani. 
Skin Diseases. (Chapt. VI.) Constipation, obstipation (acne, furunculosis). 

Pruritus ani (marginal eczema, intertrigo, ringworm, urticaria). 
Spasm of Sphincters. (See Pain, spasmodic.) 
Swelling. (See Elevations.) 
Stools. (See Feces.) 
Tenderness. (Chap. II.) Acute thrombotic hemorrhoids, fissure, anal ulcer, 

abscesses, acute internal hemorrhoids, anal cancer. 
Tumefaction. Abscess, fistula, cancer. 
Vagina, Itching of. (Chapt. VI.) Pruritus ani. 
Worms, in feces. (See Chapt. XVII.) 



INDEX OF AUTHOEITIES QUOTED 



Adler, L. G., Jr., 118 
Albutt, 260-263 
Alexander of Tralles, 253 
Andrews, 235 
Aretaeus, 253 
Ashton, 53 
Ayers, 254 



B 



Ball, 22, 24, 28, 121, 124, 184 
Bassler, Arthur, 261 
Beck, Emil G., 57, 178 
Benivieni, Antonio, 253 
Beranger and Feraud, 278 
Boas, 326 



Casagrandi and Barbagalli, 264 

Celsus, 253 

Cetti, 334 

Corsons, E. A., 291 

Councilman, 267 

Councilman and Lafleur, 253, 263 

Craig, 272 

Cripps, 30, 117, 177 

Crisler, J. A., 293 

Crossen, 49 

Czernicki, 255 



Dixon, A. F., 22 
Dudley, 50 



D 



F 



Flexner, 253, 259 
Flexner and Strong, 259 
Franck, 209 

G 

Galen, 253 

Gant, 30, 117, 118 

Griswold, V. M., 304 



Hanes, Granville S., 69, 286 

Harris, H. E., 253, 269, 285, 291 

Heller, 351 

Hensel, "Weil and Jelliffe, 341, 352 

Hertzler, 304, 305 

Hertzler, Brewster and Rogers, 304 

Hippocrates, 253 

Hirsch, A., 254 

Hirst, 51 

Holl, 29 



Jelks, John L., 245, 249, 253, 275 
Jurgens, 263 



Kartulis, 253, 283 
Kelly, 68 
Kelsey, 206 
Krouse, Louis J., 125 



LeRoy, Louis, 288 
Leukart, 348, 356 



M 



McDill, 253-284 

McGregor, 254 

MacMillan, 96 

Martin, Thomas Charles, 25, 62, 102 

Maurel, 334 

Meyer, 292 

Montgomery, 53 

Murray, D. H., 71, 113, 290 

O 
Osier, 253, 254, 262, 285 



Pennington, J. R., 159 



365 



366 



INDEX 



s 



Schmidt, 336 

Schmidt and Strassburger, 339, 341 

Shiga, 253, 259 

Simon, 348, 357 

Steele, 340 

Sternberg, Surgeon General, 253 

Stiles, 351 

Strassburger, 340 

Strauss, 334 

Strong and Musgrave, 253, 267, 285 



Teachnor, Wells, 96 
Terrell, E. H., 210 
Thayer, 356 
Thevenol, 257 



Thibault, Henry, 304 

Thomas, 253 

Thompson, 29 

Thompson and Ball, 27 

Turck, 96 

Tuttle, 33, 68, 117, 144, 245, 247, 249, 



V 



Van Jakseh and Cagney, 335, 336, 341, 
350, 353, 354, 355, 358 



W 

Wallis, 119, 177, 238 
Weir, Eobert, 292 
Woodward, 253, 255 



INDEX 



Abscess, ischiorectal, 54, 154 
diagnosis of, 154 
incision of, 153, 155 
symptoms of, 154 
treatment of, 155 
intermural, 150 
diagnosis of, 152 
proctoscopic view of, 151 
treatment of, 152 
marginal, 147 

examination of, 149 
symptoms of, 148 
treatment of, 149 
of the anorectal region, 144, 156 

classification of, 144 
perianal, local anesthesia for, 315 
perineal, 145 

diagnosis of, 147 
treatment of, 147 
rectal, 329 
subtegumentary, 147 
examination of, 149 
symptoms of, 148 
treatment of, 149 
tegumentary, 145 
diagnosis of, 147 
treatment of, 147 
Acarus scabei as cause of pruritus ani, 

111 
Adrenalin in treating hemorrhoids, 206 
Amebae, examination of feces for, 265, 

267 
Amebic dysentery, 262 

character of feces in, 360 
chronic, 290 
secondary, 290 
Amoeba coli mitis, 264, 347 
dysenterice, 263 
Mstolytica, 263 
Anal canal, anatomy of the, 21, 22, 23 
fissure, 127, 141 
cause of, 127 
diagnosis of, 130 

from tearing-down of crypt of 
Morgagni, 132 



Anal fissure — Cont'd. 

local anesthesia for, 315 
multiple, 131 
treatment of, 133 

author's operation in, 139 

excision in, 139 

ichthyol in, 133 

incision in, 136 

injection in, 135, 136 

nitrate of silver in, 135 

ointment in, 135 

scarlet-red ointment in, 135 

suppositories in, 135 

surgical, 136 
with sentinel pile, 129, 130, 132 
fistuhe, 157, 182, 329 

blind external, (see Sinus) 

treatment of, (see Sinus) 
blind internal, (see Sinus) 

diagnosis of, (see Sinus) 

treatment of, (see Sinus) 
direct complete, 159 
excision of, 166 
horseshoe, 158 
in tuberculous patient, 181 

diagnosis of, 182 

symptoms of, 182 

treatment of, 182 
incision of, 163 

injection of bismuth paste in, 178 
ligature operations for, 170 
local anesthesia for, 317 
mucocutaneous, 177 
multiple complete, 159 
simple complete, 159 

diagnosis of, 161 

symptoms of, 159 

treatment of, 163 
submucous tract, 177 
varieties of, 158 
papillse, anatomy of, 23, 234 
hypertrophy of, 228, 239 

local anesthesia for, 317 
sinus, 159 
external, 172 

treatment, 172 



367 



368 



INDEX 



Anal sinus — Cont'd, 
internal, 172 
diagnosis, 174 
treatment, 176 
ulcer, 142 

excision of, 142 

after-treatment of, 143 
Anatomy, 21-33 

of the anal canal, 21, 23 

papillae, 23 
of the anus, 21 
of the coccyx, 28, 30 
of the columns of Morgagni, 26 
of the crypts of Morgagni, 25 
of the folds of Houston, 26 
of the ischiorectal fossa, 30 
of the ligaments, 29 
anococcygeal, 29 
lateral, 29 
of the mesosigmoid, 31 
of the muscles, bulbocavernosus, 22, 
28 
gluteus maximus, 28 
iliococcygeus, 27 
levator ani, 27, 28 
pubococcygeus, 28 
puborectalis, 22, 29 
rectourethralis, 22, 27 
sphincter recti, 29 
external, 22, 23, 28 
internal, 22, 26 
transversus perenei, 28 
of the rectal valves, 26, 100 
of the rectum, 22, 24, 25 
of the blood supply, 31 
of the lymphatics, 32 
of the nerve supply, 33 
of the venous supply, 32 
of the sacrum, 30 
of the sigmoid colon, 31 
Anemia as symptom of rectal disease, 

39 
Anesthesia, local, for operations on 
hemorrhoids, 211 
technic of the use of, 302, 320 
Anesthetizing the sphincters, amount 
of distention necessary for, 
312 
point of puncture for, 310 
Anguillula intestinalis, 356 

stercoralis, 356 
Animal parasites in feces, 347 
Arikylostoma du-odenale, 351 
Anorectal region, abscess of the, 144-156 
Anoscope, fenestrated, author's 57 
Kelly, 59 
with oblique opening, author's, 57 



Anoscopy, 58 

in diagnosis of hemorrhoids, 198 
instruments for, 58 
knee-shoulder position in, 54-56 
posture and method in, 60 
Antiseptics in treatment of amebic dys- 
entery, 282 
Anus, anatomy of the, 21 

congenital defect or malformation of, 

examination for, 69 
eversion of, 49, 50 

vaginal, 69 
imperforate, 66-69 
quadrants of the, 311 
Aposthesin for local anesthesia, 302 
Appendico-cecostomy for chronic amebic 

dysentery, 293 
Arteries of the rectum, 31 
Ascaris lumbricoides, 350 
Atresia ani vaginalis, complete, 67, 69 
incomplete, 68, 69 



Bacillus coli communis, 257 

dysenteries, 259 
Backache, sacral, as symptom of rec- 
tal disease, 38 
Bacteria of symbiosis, 265 
Balantidium coli, 224, 348 
Ball's operation for pruritus ani, 121- 

125 
Krouse's modification of, 125 
Beck's bismuth paste, injection of, 57, 

178 
Benzidin test for occult blood in feces, 

346 
Beta-eucain for local anesthesia, 302 
Bile in physiology of defecation, 78 
pigment in feces, clinical significance 

of, 342 
Bilirubin in feces, clinical significance 

of, 343 
Bismuth meal, radiograph of, 80, 81 
paste, injection of fistulous tracts 

with, 57, 178 
Bivalve rectal speculum, 196 
Blackwash for pruritus ani, 117 
Bleeding as symptom of hemorrhoids, 

190 
of rectal disease, 35, 344 
Blood in feces, clinical significance of, 

35, 344 
supply of the rectum, 31 
Bloodless operation for hemorrhoids, 

author's, 216 
Botlirioceplialus latus, 358 



INDEX 



369 



Bougie, Wales, 96, 319, 329 
Bulbocavernosus muscle, anatomy of 
the, 22, 28 



Calomel for dysentery, 282 
Cancer, differential diagnosis of hem- 
orrhoids from, 230 
of the rectum, 323 

proctoscopic view of, 323 
with multiple fistulse, 325 
Carbolic acid for injection of hemor- 
rhoids, 209 
for pruritus ani, 117 
Case reports of amebic dysentery, 273 

with pellagra, 275, 276 
Cauterization, linear, for prolapse of 
the rectum, 297 
by actual cautery, 301 
by nitric acid, 300 
Cecum, ptosis of, 82, 83 
Cercomonas intestinalis in acute catar- 
rhal dysentery, 257 
Cestode worms, 356 
Chemical examination of feces, 339 
Chloretone for dysentery, 283 
Cholera nostras, character of feces in, 

360 
Citrine ointment for pruritus ani, 117 
Clamp and cautery operation for hem- 
orrhoids, 224 
Climate in etiology of dysentery, 254 
Cocain for local anesthesia, 302 

hydrochlorate in dysentery, 283 
Coccyx, anatomy of the, 28, 30 

examination of the, 51 
Colitis, 253 

mucomembranous, character of feces 
in, 360 
Colon, atrophy of descending, 71 
hypertrophy of, 74, 76 
overdistention of, 72 
sigmoid, anatomy of the, 31 
Coloptosis, 77 
Colostomy, 328 

Columns of Morgagni, anatomy of, 26 
Concretions, removal of, from rectum or 

sigmoid, 331 
Congenital defects of anus or rectum, 

examination for, 69 
Constipation, 70, 105 

as symptom of rectal disease, 38 
definition of, 71 
diagnosis of, 85 

proctoscopy in, 85, 86 
radiography in, 86 



Constipation — Cont 'd. 
etiologic factors in, 79 
neglect as, 90 
use of vegetables as, 90 
use of water as, 90 
treatment of, 90 

author's method for, 96 
diet in, 90 
exercise in, 90 
inflation of rectum in, 96 
massage in, 94, 96 
mechanical dilatation in, 96 
nux vomica in, 99 
ox gall in, 99 
pancreatin in, 99 
petrolatum in, 99 
pneumatic dilator for, 96 
tamponing the rectum in, 96 
Coprology, 333 

Corrugator cutis ani muscle, 21 
Cryptitis, 238 

treatment of, 239 
Crypts of Morgagni, anatomy of, 23 
tearing-down of, cause of anal fis- 
sure, 132 



D 

Defecation, physiology of, 73 
De Vilbiss rectal speculum, 152 

spray tube, 241 
Diagnosis of abscess, intermural, 152 
marginal, 149 
perineal, 145 
rectal, 149 
submucous, 151 
subtegumentary, 149 
tegumentary, 147 
of anal fissure, 130 

fistuhe, simple complete, 161 
tuberculous, 182 
of constipation, 85 
of dysentery, acute catarrhal, 258 
amebic, 278 
diphtheritic, 258 
sporadic bacillary, 257 
of fecal impaction, 107 
of hemorrhoids, 194 

differential, 199 
of hypertrophied anal papilla?, 235 
of proctitis and sigmoiditis, acute, 
241 
chronic atrophic, 251 
chronic hypertrophic, 245 
of prolapse of the rectum, 296 
of pruritus ani, 113 
of rectal polypus, 228 
of sinus, 174 



370 



INDEX 



Diarrhea as symptom of rectal disease, 

38 
Diet in constipation, 90 

in dysentery, 256 
Digital examination, 45 
finger cots for, 43, 45 
in diagnosis of hemorrhoids, 197 
lubricants for, 45 
of coccyx, 51 
position for, 46 
correct, 47 
incorrect, 46 
lithotomy, 48-52 
rectoabdominal, 52, 53 
vaginorectal, 49 
Dilatation, mechanical, for constipa- 
tion, 96 
Dilator, pneumatic, for constipation, 96 
Diphtheritic dysentery, 258 

enteritis, character of feces in, 359 
Director, grooved, 167 
Discharge as symptom of rectal disease, 

37 
Disturbances, general, as symptom of 
rectal disease, 39 
urinary, as symptom of rectal disease, 
39 
Doclimius duodenalis, 351 
Douglas' pouch, 30 
Dressing, rectal, 121 
Dysenteric ulceration on valves of 

Houston, 270 
Dysentery, 253, 293 
acute catarrhal, 257 
diagnosis of, 258 
etiology of, 257 
pathology of, 257 
prognosis of, 258 
symptoms of, 257 
amebic, 262 

case reports of, 273 
character of feces in, 360 
chronic, 290 

appendico-cecostomy for, 290 
complications of, 274 
diagnosis of, 278 
etiology of, 263 
pathology of, 267 
pellagra with, 276 
prognosis of, 278 
secondary, 290 
sequelae of, 274 
symptoms of, 272 
synonyms of, 262 
treatment of, 278 
antiseptics in, 282 
dietetic, 279 



Dysentery, amebic, treatment — Cont 'd. 
irrigation of colon in, 284 
laxatives, in, 281 
prophylactic, 278 
remedial, 280 
vaccines in, 289 
character of feces in, 360 
definition of, 253 
diphtheritic, 258 

complications of, 260 
definition of, 258 
diagnosis of, 259 
etiology of, 259 
pathology of, 259 
secondary, 260 
~~ prognosis of, 260 
symptoms of, 260 
symptoms of, 259 
etiology of, 254 
climate in, 254 
drinking water in, 256 
foods in, 256 
poor hygiene in, 254 
race in, 254 
season in, 254 
sex in, 254 

topography and condition of soil 
in, 255 
flagellate, 260 
etiology, 260 
treatment, 261 

transduodenal, 261 
general considerations of, 253 
geographical distribution of, 254 
history of, 253 
sporadic bacillary, 257 
diagnosis of, 258 
etiology of, 257 
pathology of, 257 
prognosis of, 258 
symptoms of, 257 
synonyms of, 253 



E 



Electric magnifying headlight, 43 
Elevations as symptom of rectal dis- 
ease, 37 
Emetin in dysentery, 284 
Enemata for pruritus ani, 118 
Entamoeba histolytica, 263, 266, 269 
Enteritis, diphtheritic, character of fe- 
ces in, 359 
Erythema, treatment of, 116 
Etiology of acute proctitis and sigmoid- 
itis, 240 
of constipation, 79 



INDEX 



371 



Etiology — Cont 'd. 
of dysentery, 254 

acute catarrhal, 257 

amebic, 254 

diphtheritic, 259 

sporadic bacillary, 257 
of prolapse of the rectum, 295 
Eversion of anus, 48 

vaginal, 49 
Examination of feces, chemical, 339 

clinical, 336 

for amebse, 267, 347 

microscopic, 335 
of hypertrophied anal papillae, 235 
of marginal abscess, 149 
of patient, 40-69 

anoscopy in, 58 

digital, 45 

electric headlight for, 43 

eversion of anus in, 48 

for congenital defects or malfor- 
mation, 69 

internal inspection in, 52 

knee-shoulder position for, 54-56 

lithotomy position for, 50 

location of rooms for, 40 

proctoscopy in, 60, 62 

rectoabdominal, 52, 53 

rooms and furniture in, 40 

sigmoidoscopy in, 62-67 

Sims' position for, 47 

squatting position for, 52, 55 

vaginorectal, 49 
Exercise in constipation, 90 
Excision of anal fissure, 139 

fistula, 166 

ulcer, 142 
of hemorrhoids, 215 

submucous, 224 
External spincter muscle, anatomy of, 



Fecal impaction, 106-109 
cause of, 106 
diagnosis of, 107 
symptoms of, 106 
treatment of, 108 

author's massage bag in, 109 
liquid petrolatum in, 108 
peroxid of hydrogen in, 108 
Feces, amount of, 334 

and their clinical examination, 333- 

360 
animal parasites in, 347 
character of, in acute intestinal ca- 
tarrh, 359 



Feces, character of — Cont'd, 
in amebic dysentery, 360 
in chronic inflammation of intes- 
tines, 359 
in cholera nostras, 360 
in diphtheritic enteritis, 359 
in dysentery, 360 
in mucomembranous colitis, 360 
color of, 334 

consistency and form of, 334 
duration of passage of, 333 
examination of, chemical, 339 

estimation of lost albumin resi- 
due in, 341 
fermentation test in, 340 
reaction in, 339 
sublimate test in, 339 
clinical, 336 

test-diet in, 336 
for amebse, 267, 347 
microscopic, 338 
significance of tests in, 342 
bile pigment, 342 
bilirubin, 342 
blood, 344 

excess of connective tissue, 344 
excess of undigested muscle- 
fiber, 344 
fat, 343 
gallstones, 346 
hyaline cells, 342 
mucus, 342 

pathologic albumin fermenta- 
tion, 342 
pathologic carbohydrate fermen- 
tation, 342 
pus, 342 

remnants of meat, 344 
semidigested cells, 342 
general characteristics of, 333 
macroscopic elements in, 335 
microscopic elements in, 335 
number of stools of, 333 
odor of, 334 
Fermentation apparatus, Steele's, 340 
test for chemical examination of fe- 
ces, 340 
Finger cots for digital examination, 45, 

146 
Fissure, anal, 127-141 

differential diagnosis of hemor- 
rhoids from, 199 
local anesthesia for, 315 
Fistula, anal, 127-141, 331 

blind external, (see Sinus) 

internal, (see Sinus) 
communicating with other organs, 
331 



372 



INDEX 



Fistula, anal — Cont'd. 

complete, complicated, 164 
direct, 159 
multiple, 159 
simple, 159 
excision of, 166 
in tuberculous patient, 181 
incision of, 163 
ligature operations for, 170 
local anesthesia for, 317 
mucocutaneous, 177 
submucous tract, 177 
Folds of Houston, anatomy of, 26 
Foods in etiology of dysentery, 256 
Forceps, author's hemorrhoidal, 206 
long aligator, 58 
sharp-toothed or pronged, 140 
T-, 122 
Foreign body, history of swallowing, 
calls for rectal examination, 39 
local anesthesia in removal of, 318 
Formalin solutions for dysentery, 287 
Formalin-boric solutions for dysentery, 

286 
Fossa, ischiorectal, anatomy of, 30 
Furniture for examination of patient, 
40 



G 



Gallstones in feces, clinical significance 

of, 346 
Gluteus maximus muscle, anatomy of 

the, 28 

H 

Hanes position in sigmoidoscopy, 64, 65, 

68 
Helminthiasis, 349 

Hemorrhage as symptom of hemor- 
rhoids, 190 
of rectal disease, 35 
diseases causing, 35 
Hemorrhoidal forceps, author's, 206 
Hemorrhoids, 183-227, 313 
acute thrombotic, local anesthesia 
for, 314 
removal of, 225 
causes of, 187 
diagnosis of, 194 
anoscopy in, 198 
differential, 199 
from cancer, 200 
from enlarged papillae, 202 
from fissure, 199 
from polypi, 202 
from prolapse, 203 



Hemorrhoids, diagnosis of, differential 
— Cont 'd. 
from protrusions, 202 
from ulcer, 200 
from venereal warts, 203 
digital examination, 197 
proctoscopy in, 198 
sigmoidoscopy in, 199 
external, 186 
cutaneous, 189 
distention of, with sterile water, 

223 
integumentary, 186 

removal of, 226 
local anesthesia for, 313 
thrombotic, 186 
varicose, 187 
internal, 187 

anesthetized, 197, 202 
capillary, 187 
granular, 187 
prolapsing, 193-195 
varicose, 187 
interno-external, 184-186 

injected for operation, 199, 201 
prolapsing, distention necessary for 

anesthesia in, 197 
symptoms of, 190 
bleeding, 190 
pain, 192 
prolapse, 193 
treatment of, 205 
adrenalin in, 206 
injection, 207 

carbolic acid for, 207 
operative, 211 

author's bloodless, 216-224 
clamp and cautery, 224 
excision in, 215 
other methods of, 225 
submucous excision in, 224 
Whitehead, 225 
palliative, 174, 205 
varieties of, 186 
with pruritus ani, 114 
Hepatic abscess complicating amebic 

dysentery, 274 
Herpes, treatment of, 116 
Hilton, white line of, 25 
Holland's modification of Weber's test 
for occult blood in feces, 346 
Hookworms, 351, 352 
Hypertrophy of the anal papillae, 228- 
239 
diagnosis of, 235 
differentiated from polypus, 235 
examination of, 235 



INDEX 



373 



Hypertrophy of anal papillaB — Cont'd, 
local anesthesia for, 317 
proctoscopic view of, 236 
symptoms of, 237 
of the rectal valves, local anesthesia 
for, 317 



Ichthyol for acute proctitis, 245 
for anal fissure, 133 
for chronic proctitis, 249 
Idiopathic pruritus ani, 113 
Ilioeoecygeus muscle, anatomy of, 27 
Impaction, fecal, 106-109 
Imperforate anus, 66-69 
Incision of anal fissure, 136 

fistula, 163 
Inflammation of intestines, chronic, 

character of feces in, 359 
Inflation of rectum in constipation, 96 
Injection of anal fissure, 135, 136 
of bismuth paste; 57, 178 
of local anesthetic, for operating on 
hemorrhoids, 200, 203, 213 
point of puncture for, 312, 313 
treatment of hemorrhoids, 207 
Instrument and dressing sterilizer, 41 

sterilizer, 41 
Intermural abscess, 150 
Internal sphincter muscle, anatomy of, 

22, 23, 26 
Interno-external hemorrhoids, 184, 186 
Intestinal catarrh, acute, character of 
feces in, 359 
ulcer, edge of, 269 
Iodin for dysentery, 287 
Ipecacuanha for dysentery, 283 
Irrigations of colon for acute catarrhal 
proctitis, 243 
for amebic dysentery, 284 
with J elks' colon tube, 245 
Ischiorectal abscess, 54, 154 
fossa, anatomy of the, 30 
Itching as symptom of rectal disease, 

36 
Itch-mite as cause of pruritus ani, 111 



Jelks' recurrent-flow soft-rubber colon 
tube, 245, 286 



Kelly anoscope, 59 

sigmoidoscope, 63, 68 
Kerosene oil for dysentery, 286 



Klunge's aloin test for occult blood in 

feces, 346 
Knee-elbow position, 56 
Knee-shoulder position for diagnosis of 
constipation, 86 
for internal inspection, 54 
for proctoscopic examination, 56, 

59 
for spraying rectum, 243, 245 
in anoscopy, 56, 59 
Krameria for chronic proctitis, 249 

for spraying rectum, 245 
Krouse's modification of Ball's opera- 
tion for pruritus ani, 125 



Laxatives in treatment of amebic dys- 
entery, 281 
Levator ani muscle, anatomy of, 27-28 
Ligaments, anatomy of the, 29 
anococcygeal, 29 
lateral, 29 
Ligature carrier, author's blunt- 
pointed, 209 
author's rubber, 103, 104 
operation for anal fistula, 170 
Limitations of local anesthesia and 

office treatment, 321-332 
Linea dentata, 23, 25, 234 
Lithotomy position for digital exami- 
nation, 50, 51 
for surgery of pruritus ani, 119 
Liver in physiology of defecation, 78 
Local anesthesia, amount of dilatation 
of spincter under, 312, 315 
anesthetic agents for, 302 
apothesin for, 302, 303 
beta-eucain for, 302 
cocain for, 302 
contraindications to, 322 
anal fistula, 329 
cancer of the rectum, 323 
hemorrhoids, 330 
fistulae communicating with other 

organs, 331 
prolapse of the rectum, 331 
rectal abscesses, 329 
removal of concretions, 331 
stricture of the rectum, 328 
ulceration of the bowel, 328 
for anal fissure, 315 

fistula, 317 
for hemorrhoids, 211, 313 
acute thrombotic, 314 
external, 313 



374 



INDEX 



Local anesthesia — Cont 'd. 

for hypertrophied anal papillae, 317 

rectal valves, 317 
for perianal abscess, 315 
for removal of benign perianal 
growths, 318 
for sinus, 317 
of foreign bodies, 318 
in posterior internal proctotomy, 

319 
instruments for, 307 
limitations of, 321 
needle for, 308 
quinin and urea hydrochlorid for, 

303-306 
sterile water for, 306 
technic of, 302-320 
general, 308 
in special cases, 313 
Lubricants for digital examination, 45 
Lymphatics of the rectum, 32 

M 

Malformation of the anus or rectum, 

examination for, 69 
Marginal abscess, 147 
Martin proctoscope, author's modifica- 
tion of, 61 
Massage bag, author's dilating, 95, 96, 
97 
in constipation, 96 
rectal, author's method of, 96 
Medio cannulata, 357 
Megacolon, 74, 76 

Menstruation, crampy, painful, and 
scanty, as symptom of recta] 
disease, 39 
Mesosigmoid, anatomy of the, 31 
Microscopic elements in feces, 335 

examination of feces, 335 
Morestin, lesser sphincterian nerve of, 

33 
Morgagni, columns of, anatomy of, 26 

crypts of, anatomy of, 23 
Mucomembranous colitis, character of 

feces in, 360 
Mucus as symptom of rectal disease, 37 

clinical significance of, in feces, 342 
Muscle, bulbocavernosus, 22, 28 
corrugator cutis ani, 21 
gluteus maximus, 28 
iliococcygeus, 27 
levator ani, 27, 28 
pubococcygeus, 28 
puborectalis, 22, 29 



Muscle— Cont 'd. 

rectourethralis, 22, 27 
sphincter recti, 29 

external, 22, 23, 28 

internal, 22, 26 
transversus perenei, 28 

N 

Nematodes, 349 

Nerve supply of the rectum, 33 

Nerves of the rectum, 33 

Neuralgia of the rectum caused by hy- 
pertrophied papillae, 237 

Nitrate of silver for anal fissure, 134 
for pruritus ani, 118 

Nitric acid cauterization for prolapse 
of the rectum, 300 

Nux vomica in treatment of constipa- 
tion, 99 

O 

Obstipation, 100-105 

causes of, 73 

definition of, 72 

rectal valves in, 100 
Odor of discharge as symptom of rec- 
tal disease, 38 

of feces, 334 
Ointment for anal fissure, 134 

for dysentery, 285 

for pruritus ani, 116, 117 
Operating-room, 40 

-table, 42 
Opium for dysentery, 282 
Oxgall in treatment of constipation, 99 
Oxyuris vermioularis, 350 

as cause of pruritus ani, 111 



Pain as symptom of hemorrhoids, 192 

of rectal disease, 34-39 
Palpation of rectum, 52 

rectoabdominal, 52 
Pancreatin in treatment of constipa- 
tion, 99 
Papillae, anal, anatomy of, 23 
hypertrophy of, 228-239 

differential diagnosis of, from 
hemorrhoids, 202 
Paramoscium coli, 257, 265, 348 
Parasites, animal, 347 
Amceba coli, 347 
Anguillula intestindlis, 356 

stercoralis, 356 
Ankylostoma duodenale, 351 



INDEX 



375 



Parasites — Cont 'd. 

Ascaris luiribricoides, 349 
Balantidium coli, 348 
Bothrioceplialus latus, 358 
cestode worms, 356 
Dochmius duodenalis, 351 
hookworm, 351, 352 
Medio cannulata, 357 
nematodes, 349 
Oxyuris vermicularis, 350 
pinworm, 350 
protozoa, 347 
round worms, 349 
seatworm, 350 
Strongylus duodenalis, 351 
Taenia nana, 358 
saginata, 357 
solium, 356 
tapeworms, 356-359 
threadworm, 350 
Trichina spiralis, 354 
Trichinae, 355 

Triclioceplialus dispar, 353-354 
Uneinaria americana, 352 

duodenalis, 351 
whip worm, 353 
worms, 349 
Pathology of dysentery, acute catarrhal, 
257 
amebic, 267 
diphtheritic, 259 
sporadic bacillary, 257 
Patient, examination of the, 4.0-69 
Pedicidus pubis, treatment of, 116 
Pellagra with amebic dysentery, 276 
Perianal abscess, local anesthesia for, 

315 
Perineal abscess, 145 
Peristalsis intestinal, 73 
Peroxid of hydrogen in fecal impaction, 
108' 
injection of, for determining in- 
ternal opening of fistula, 54 
Petrolatum liquid in treatment of con- 
stipation, 99 
in fecal impaction in hemorrhoids, 
227 
Physiology of defecation, 73 
bile in, 78 

chemical reaction of stomach con- 
tents in, 75 
creation of gases in, 75 
liver in, 78 
movements of intestines in, 73 

of respiration in, 75 
peristaltic action in, 73 
stimulation by particles of food in, 
75 



Pinworms, 350 

Polyposis multiple, 232, 233 

Polypus rectal, 228, 230 

differentiated from hemorrhoids, 
202 
from hypertrophied papillae, 235 
Position assumed by patients, in ano- 
rectal disease, 148 
exaggerated lithotomy, in sigmoid- 
oscopy, 62 
inverted or Hanes, in sigmoidoscopy, 

64, 65, 68 
knee-elbow, 56 

knee-shoulder, for anoscopy, 56, 59, 
60 
for internal inspection, 56-59, 60 
for proctoscopic examination, 53, 

56 
for spraying rectum, 243, 292 
lateral, for digital examination, 46, 
47 
for surgery of pruritus ani, 119 
left lateral, for external inspection, 

44 
lithotomv, for digital examination, 
62 
for surgery of pruritus ani, 119 
of patient for introduction of colon 

tube, 289 
Sims', for digital examination, 46, 
47 
for dilating rectum, 97 
for external inspection, 44 
Pouch, Douglas', 30 

rectovesical, 30 
Probe, silver, 58 

Proctitis and sigmoiditis, 240-252 
acute, 240 

catarrhal, 242 
diagnosis of, 241 
etiology of, 240 
symptoms of, 241 
treatment of, 242 
chronic, 247 
atrophic, 249 

symptoms of, 250 
treatment of, 251 
hypertrophic, 247 
diagnosis of, 248 
symptoms of, 248 
treatment of, 248 
Proctoscope, author's four-inch operat- 
ing, 101 
author 's modification of Martin, 61 
Proctoscopic view of cancer of the rec- 
tum, 323 
of hypertrophied anal papilla?, 236 
of submucous abscess, 151 



376 



INDEX 



Proctoscopy, 59-66 

in diagnosis of hemorrhoids, 198 
technic of, 62 
without instruments, 60 
Proctotomy, posterior, internal, for an- 
nular stricture, 319 
Prolapse as symptom of hemorrhoids, 
193 
differential diagnosis of hemorrhoids 

from, 303 
of the rectum, 331 
in children, 294-301 

cauterization of, 300, 301 
concealed, 295, 296, 299 
diagnosis of, 296 
etiology of, 295 
symptoms of, 296 
treatment of, 297 
Protozoa, 347 

Protrusions as symptom of rectal dis- 
ease, 37 
differential diagnosis of hemorrhoids 
from, 202 
Pruritus ani, 110-126 
after-treatment of, 126 
caused by hypertrophied papillae, 237 
causes of, 110 
characteristic cracking of, 111 

itching of, 115 
diagnosis of, 113 
idiopathic, 113 
treatment of, 115 

author's operation in, 122 
Ball's operation in, 121 

Krouse's modification of, 125 
blackwash in, 117 
carbolic acid in, 117 
dusting powder in, 116 
enemata in, 118 
lotions in, 117 
mechanical vibrator in, 118 
nitrate of silver in, 118 
ointment in, 116, 117 
citrine, 118 
scarlet-red, 118 
prescriptions for, 116, 117 
removal of kite-shaped flap of skin 
in, 120 
streptococcus fecalis in, 113, 115 

surgical measures in, 119 
with hemorrhoids, 114 
Ptosis of cecum, 82, 83 
Pubococcygeus muscle, anatomy of, 28 
Puborectalis muscle, anatomy of, 27-29 
Pus in feces, clinical significance of, 
344 



Quadrants of anus, 311 
Quinin and urea hydrochlorid for local 
anesthesia, 303-307 
for injection method, 210 



E 



Eace in etiology of dysentery, 254 
Eadiograph of bismuth meal, 80, 81 
Eadiography, in diagnosis of constipa- 
tion, 73 
Eectal abscesses, 329 
dressing, 121 

massage, author's method of, 96 
polypus, 228, 230 
diagnosis of, 228 
fibroid, 228 
granular, 228 
symptoms of, 230 
treatment of, 229 
retractor, modified from Sims' specu- 
lum, 209 
speculum, bivalve, 196 

De Vilbiss, 152 
spray tube, author's, 242 
valves, 100 

anatomy of the, 26, 100 
valvotomy, author's operation, 104 
Eectoabdominal examination, 52, 53 

palpation, 52 
Eectourethralis muscle, anatomy of the, 

22, 27 

Eectovesical pouch, 30 

Eectum, anatomy of the, 22, 24, 25 

arteries of the, 31 

blood supply of the, 31 

cancer of the, 323 

proctoscopic view of, 323 
congenital defect or malformation of, 

examination for, 69 
inflation of the, in constipation, 96 
lymphatics of the, 32 
nerve supply of the, 33 
nerves of the, 33 

neuralgia of the, caused by hyper- 
trophied papillae, 237 
palpation of the, 52 
prolapse of the, 331 

in children, 294-301 
relations of the, 30 
stricture of the, 319, 328 
symptoms which should call attention 

to the, 34-39 
tamponing the, in constipation, 96 
ulcer of the, 244 



INDEX 



377 



Eectum — Cont 'd. 

veins of the, 32 

venous supply of the, 32 
Eestlessness in children as symptom of 

rectal disease, 39 
Retractor, rectal, 209 
Ringworm as cause of pruritus ani, 111 

treatment of, 117 
Rooms for examination of the patient, 

40 
Round worms, 349 

S 

Sacral backache as symptom of rectal 

disease, 38 
Sacrum, anatomy of the, 30 
Scabies, treatment of, 116 
Scarlet-red ointment for anal fissure, 
135, 138 
for pruritus ani, 118 
Scissors, author's angular rectal, 101 

curved on the flat, sharp-pointed, 122 
Season in etiology of dysentery, 254 
Seatworms, 350 
Sentinel pile, 130 

with anal fissure, 129 
Sex in etiology of dysentery, 254 
Sigmoid colon, anatomy of the, 31 
Sigmoiditis, 240-252 
acute, 242 

chronic atrophic, 247 
hypertrophic, 247 
Sigmoidoscope, Kelly, 63, 68 

with author's tilting obturator, 63, 
68 
Sigmoidoscopy, 67-69 

exaggerated lithotomy position in, 62, 

69 
in diagnosis of hemorrhoids, 199 
inverted or Hanes position in, 64, 65, 
68 
Sims position for digital examination, 
46, 47 
for dilating rectum, 97 
for external inspection, 44 
for internal inspection of anal 
canal, 58, 60 
Soil in etiology of dysentery, 255 
Spasm as symptom of rectal disease, 35 
Speculum, bivalve rectal, 196 

De Vilbiss rectal, 152 
Sphincter recti muscle, anatomy of the, 
29 
tight contracted, 237 
Spray tube, author's rectal, 242 

De Vilbiss, 241 
Squatting position for diagnosis, 52, 55 



Staphylococcus cause of tegumentary 

abscess, 147 
Sterilizer, instrument and dressing, 41 
Stomach contents, chemical reaction of, 

75 
Stools, altered, as symptom of rectal 

disease, 38 
Streptococcus foecalis cause of pruritus 

ani, 113, 115 
Stricture of the rectum, 319, 328 

posterior internal proctotomy for, 313 
Strongylus duodenalis, 351 
Sublimate test in chemical examination 

of feces, 339 
Submucous abscess, 150 

excision of hemorrhoids, 224 
tract, 177 
Subtegumentary abscess, 147 
Suppository for anal fissure, 135 
for dysentery, 283, 285 
for hemorrhoids, 220 
Surgical measures for pruritus ani, 119 

treatment of anal fissure, 136 
Symbiosis, bacteria of, 265 
Symptoms which should call attention 

to the rectum, 34-39 
Syringe, all-glass hypodermic, 307 
all-metal, 307 
all-rubber bulb, 53, 55 



T-forceps, 122 
Tcenia nana, 358 
saginata, 357 
solium, 356 
Tamponing the rectum in constipation, 

96 
Tapeworms, 356-359 
Tegumentary abscess, 145 
Tenderness as symptom of rectal dis- 
ease, 35 
Test, fermentation, in examination of 
feces, 340 
for estimation of lost albumin resi- 
due in feces, 341 
for occult blood in feces, benzidin, 
346 
Holland's 346 
Klunge's aloin, 346 
Weber's, 345 
sublimate, in examination of feces, 
339 
Test-diet in clinical examination of fe- 
ces, 336 
Treadworms, 350 

as cause of pruritus ani, 111 
treatment for, 117 



378 



INDEX 



Thymol for dysentery, 287 
Toilet rooms, provision for, 83, 84 
Tract, submucous, 177 
Treatment of abscess, intermural, 152 
marginal, 149 
perineal, 145 
rectal, 149 
submucous, 152 
subtegumentary, 149 
tegument ary, 145 
of amebic dysentery, 278 
of anal fissure, 133 
fistula, 163 

simple complete, 163 
tuberculous, 182 
of constipation, 90 
of cryptitis, 239 
of erythema, 116 
of fecal impaction, 108 
of hemorrhoids, 205 
of herpes, 116 
of Pediculus pubis, 116 
of proctitis and sigmoiditis, acute, 
242 
chronic atrophic, 251 
hypertrophic, 248 
of prolapse of the rectum, 297 
of pruritus ani, 115 
of rectal polypi, 230 
of ringworm, 117 
of scabies, 116 
of threadworm, 117 
Trichina, 355 

spiralis, 354 
Trichocephalus dispar, 353, 354 
Trichomonas intestinalis, 257 
Trichophyton as cause of pruritus ani, 

in 

treatment of, 117 
Tuberculous anal fistula, 181 



U 



Ulcer, anal, 142 

differential diagnosis of hemorrhoids 
from, 200 



Ulcer— Cont 'd. 

intestinal edge of, 269 

of the rectum, 244 
Ulceration of the bowel, 328 
Uncinaria americana, 352 

duodenalis, 351 
Urinary disturbances as symptom of 
rectal disease, 39 



V 



Vaginorectal examination, 49 
Valves of Houston, dysenteric ulcera- 
tion on, 270 
rectal, 100 

anatomy of the, 26, 100 
Valvotomy, 102 
needle, 101 

rectal, author's operation for, 104 
Veins of the rectum, 31 
Venous supply of the rectum, 32 
Vibrator, mechanical, for constipation, 
94 
for dilatation of sphincter, 312, 
314 

for pruritus ani, 118 



W 



Wales bougie, 96, 319, 329 

Warts, differential diagnosis of hem- 
orrhoids from, 203 

Water, drinking, in etiology of dysen- 
tery, 256 

Weber test for occult blood in feces, 
345 

Whip worm, 353 

White line of Hilton, 25 

Whitehead operation for hemorrhoids, 
225 

Worms in feces, 349 
cestode, 359 
nematode, 349 



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